Application of Lean Thinking to Health Care Development of the “Michigan Quality System” at the U of M Health System John E. Billi, M.D. Associate Dean

Application of Lean Thinking to Health Care

Development of the“Michigan Quality System”

at the U of M Health System

John E. Billi, M.D.Associate Dean for Clinical Affairs, Medical SchoolAssociate Vice President for Medical AffairsUniversity of [email protected]://sitemaker.umich.edu/jbillihttp://med.umich.edu/i/mqs/

MQS:

Quality

Safety

Efficiency

Appropriateness

Burning Platform in Healthcare

• The key is to change before the flames start• The gaps at UMHS:

– Quality: Not all diabetic patients on statins, aspirin– Safety: Still have wrong site surgery– Efficiency: Days waiting for a PICC IV line; nurse

shortage– Appropriateness: generic rate around 55%

• Bottlenecks at UMHS:– Budgeted 4% activity increase, but only have 0.8%

available bed capacity– OR shortage led to elimination of storage and doctor

workstations

• Stress of overwork (muri):– Physicians, nurses, clerks running faster– Payments dropping

Crossing the Quality ChasmIOM’s 6 Aims of Health Care

Health care should be:• Safe• Effective• Patient-centered• Timely• Efficient• Equitable - not vary due to gender,

ethnicity, geography, socioeconomic statusSource: Crossing the Quality Chasm: A New Health System for the 21st Century, Institute of Medicine, National Academy of Sciences, 2000.

Crossing the Quality Chasm 10 Rules

1. Care based on continuous healing relationships 2. Customized based on needs and values, choice and preference 3. Patient as source of control 4. Shared knowledge and free flow of information

Patients - their own information & medical knowledge 5. Evidence-based decision making 6. Safety as a system property 7. Transparency - consumers and employers data on systems

(safety, evidence-based practice, satisfaction) 8. Anticipation of needs 9. Continuous decrease in waste (the apparent target of “Lean”)10. Cooperation among clinicians (coordination)

Source: Crossing the Quality Chasm: A New Health System for the 21st Century, Institute of Medicine, National Academy of Sciences, 2000.

What is Lean in Health Care?

“The endless transformation of waste into value from the customer’s perspective”.

Womack and Jones, Lean Thinking

Lean in Health Care?• Can healthcare use:

- the Toyota Production System - product development - production- supplier management - customer support- planning

-to transform waste into value?• Can a health system use:

- fewer inputs (time, human effort, materials) - than traditional care process - to produce a wide variety of “products” - with fewer “defects” more quickly

with less stress?• Lean is not about working harder or faster, it is

about finding waste and transforming it into value our customers want.

Lean = MeanLean = Mean

• or downsizing or outsourcing or working harder…

• The Toyota Production System (TPS)– Transform waste to optimize value creation

• Lean Thinking and the Lean Enterprise– Rethink our entire business– Based on what we do that provides value to

our customers

What is “lean production”? What is “lean production”?

Source: John Shook

The 5 Steps of LeanCan Work in Healthcare

• Specify value from customer’s perspective• Identify the value stream for each

product, and remove the waste• Make value flow without interruptions

from beginning to end• Let the customer pull value from our

process• Pursue perfection

– continuous improvement– Do this every day in all our activities

Source: Womack & Jones: Lean Thinking

The clinic appointment• You call the clinic, go through 3 voice prompts, are

put on hold, and leave a message• The clerk calls you back and sets a date in 3 weeks• You arrive for the visit, check in, sit in waiting

room• You are called into the exam room, wait for doctor• The doctor sees you, saying she’s been waiting for

you to arrive; diagnoses a URI, and BP is worse• The doctor prints an antibiotic prescription, goes

to the staffroom to get it. You are allergic to that drug.

• You wait to pick up the prescriptions.• The doctor says she wants to see you back in a

week, no appointment is available.• The MA does an EKG.

The 5 Principles of Lean Work• Specify value from customer’s perspective

– A quick clinic visit• Identify the value stream for each product, and

remove the waste– Time on hold, callbacks, walking

• Make value flow without interruptions from beginning to end– No waiting

• Let the customer pull value from the process– Pull the appointment when you want it

• Pursue perfection– continuous improvement

– Every clerk, doctor and nurse works to redesign for better value to the customer

Understanding the Root Causes of Waste

The simple Toyota approach1. Go and see2. Analyze the situation3. Use one piece flow and problem alerts

(andon) to surface the problems (detect abnormal immediately)

4. Ask “Why?” 5 times– Uncovers the root causes of waste and error,

not the symptoms– Avoids blame – another form of waste (5

“whos”)– GM: “will not accept, build, or ship a defect”

From Liker. The Toyota Way

Lean Tools Are Needed in Health Care

• Standard work – 4 ways lab results get to me• Pull systems – no signal (kanban) when OR ready• One piece flow – 36 step process to make an

orthopedic appointment – PT = 27 min., LT = 23 days;- All patients arrive at 8AM

• Visual workplace – each exam room has forms in different colored, opaque folders – common ones gone

• Cellular layout – ORs are mirror images – half wrong• Multi-process (cross-trained) operators – RN clean OR• Iterative questions (5 “whys”) – patient left without

being seen in ER, due to long wait, due to long stay patient, due to lack of inpatient bed, due to gap in discharge planning…

• Andon cord – “Stop the Line” in surgery

Are Lean Tools Needed in University Operations?

• Standard work – Does each DPS staff follow clearly written standard ops, that they wrote?

• Pull systems – Can staff pull repairs or supplies JIT?• One piece flow – Do budget or capital requests

proceed without stopping through campus approval?• Visual workplace – Can managers and workers tell at

a glance how work flows, current status, problems?• Cellular layout – Have we laid out workplace for

maximum efficiency, or did it evolve?• Multi-process (cross-trained) operators – DPS/OSEH?• Iterative questions (5 “whys”) – UM sued, due to

ankle injury from visitor tripping, due to a broken step that staff stepped over for a month, due to no easy way to report repair needs and to backlog of repairs

• Andon cord – How do I report water on parking stairs?

Clinical Examples of “Right Every Time”

• Stephen Spear: Learning to Lead at Toyota– Design and specify process steps well– Embed testing in work: immediately signals a problem has

occurred. “Tell normal from abnormal right now” (Toyota President Cho)

– Improve work close to problem occurrences in time, place, process and person.

• Spear: catheter-related sepsis – a lot of little things:– No sink, no soap, no sanitizer, no doormat reminder or buzzer– Gloves missing, wrong size, old and rip, on other side of patient– 92% of nurses faced with impediments constructed ad hoc

workarounds• Laryngoscope that detects misplaced tube, signals the

operator, and downloads to QI lead• CPR chest cover gives immediate feedback on hand

position, depth, ventilation rate and depth, and stores for QI

• Paul O’Neill – know everything that went wrong, every day

Fixing Health Care From Inside, Today – Steven Spear

• Work is designed as a series of ongoing experiments that immediately reveal problems

• Problems are addressed immediately through rapid experimentation

• Solutions are disseminated adaptively through collaborative experimentation

• People at all levels of the organization are taught to become experimentalists

Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added)Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added)Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added)Cost Reduction Through The Elimination of Muda (Waste or Non-Value Added)

Leveled Production (Heijunka)Leveled Production (Heijunka)Leveled Production (Heijunka)Leveled Production (Heijunka)Leveled Production (Heijunka)Leveled Production (Heijunka)

JUST IN TIMEJUST IN TIME

Operate with the Operate with the minimumminimum resource resource required to required to consistentlyconsistentlydeliver deliver

•• JustJust what is needed.what is needed.•• In In justjust the required the required

amount.amount.•• JustJust where it is where it is

needed.needed.•• JustJust when it is neededwhen it is needed.

JUST IN TIMEJUST IN TIME

Operate with the Operate with the minimumminimum resource resource required to required to consistentlyconsistentlydeliver deliver

•• JustJust what is needed.what is needed.•• In In justjust the required the required

amount.amount.•• JustJust where it is where it is

needed.needed.•• JustJust when it is neededwhen it is needed.

JidokaJidoka

OneOne--byby--one confirmation one confirmation to to detectdetect abnormalities.abnormalities.

StopStop andand respond respond to to every abnormality.every abnormality.

Separate machine work Separate machine work from human work. from human work.

Enable machines to Enable machines to detectdetect abnormalities and abnormalities and stopstop autonomously.autonomously.

JidokaJidoka

OneOne--byby--one confirmation one confirmation to to detectdetect abnormalities.abnormalities.

StopStop andand respond respond to to every abnormality.every abnormality.

Separate machine work Separate machine work from human work. from human work.

Enable machines to Enable machines to detectdetect abnormalities and abnormalities and stopstop autonomously.autonomously.

Pull SystemPull SystemProductionProduction

One Piece Flow

Production

Takt TimeProduction

AndonAndonOperational Operational AvailabilityAvailability

Standard Work in Process

StandardWork

Materials

MachinesMachines

People

Park Nicollet Production System


To care for people the right wayTo care for people the right way



To care for people the right wayTo care for people the right way

Source: Mike Kaupa, Park Nicollet

How is Health Care Similar to Manufacturing?

• Process dependence• Huge variability, often unjustified

– Aversion to standardization• Pressure to innovate and use new

technology• Need for high reliability systems

(patient safety leaders learn from airlines, nuclear power industry)

• Lack of embedded testing– No “instant awareness of every error”

• Trillion dollar industry• Continuous Quality Improvement orientation

What Advantages Does Lean in Health Care Have

Over Manufacturing?• We expect change: new treatments, drugs, devices • We have scientific literature to guide us • We accept standardization in research protocols • We (mostly) accept standardizing treatment of

common conditions:– “evidence-based medicine” and practice guidelines

• We accept standardization to improve patient safety

• We use root cause analysis in safety and quality• We are working on transparency to improve safety• We have external pressures for efficiency, safety

and quality– Pay for performance– Public reporting

Use Lean tools to transform waste into value from the customer’s

perspective. Is There Waste (Muda) in Health

Care?• Defects in products• Overproduction of

goods• Inventories of goods

awaiting future processing or consumption

• Unnecessary movement of workers

• Overprocessing

• Unnecessary transport of goods

• Waiting(for process equipment to finish or on an upstream activity)

• Design of goods and services which do not meet users’ needs

Do the Eight Forms of Waste Make Sense in University Operations

Overproduction/Production of Unwanted Products:

Material Movement and Worker Motion:

Waiting:

Over-processing:

Inventory:

First Time Quality Problems: Defects requiring correction:

Wasted Creativity of Employees:

Eight Forms of Waste in Healthcare

Overproduction and Production of Unwanted Products: The most important form of waste – leads to all the others.

• Any health care service that does not add value to the patient

• Antibiotics for respiratory infections• CT screening for coronary disease• Medication given early, testing and treatment done

ahead of time to suit staff schedules and equipment use

• Appropriateness – the key dimension of QI in health!Material Movement: • Moving patients, meds, specimens, samples,

equipmentWorker Motion: • Searching for patients, meds, charts, supplies,

paperwork• Long clinic halls• No printer in exam room for prescriptions, patient

education

Adapted From Long, Mersereau, Billi

Eight Forms of Waste of Healthcare

Waiting:• ER staff waiting for admission, can’t see next

patient• Waiting for test results, records, information • Nurse waits for med, blood draw, transport, OR

cleaningOver-processing: • Bed moves, retesting, repeat paperwork, repeat

registration, multiple consent forms, logging requests

Inventory: • Bed assignments, pharmacy stock, lab supplies,

specimens awaiting analysis• Patient waiting for anything – tests, visits,

discharge, phone cuesCorrection of defects: • Medication errors, wrong patient, wrong procedure,

missing or incomplete information, blood re-draws, misdirected results, wrong bills

Adapted From Long, Mersereau, Billi

Genesis ofLean Thinking at UMHS

1. Why Lean?2. “Michigan Quality System”

concept3. GM Agreement4. Two tracks:

• Model lines• Internal awareness and training

programs

5. Coordination across UMHS units

Why Lean?• Best way to:

– Transform waste into value – Reduce errors and quality problems– Decrease our stress

• Defines value from the customer’s perspective

• Focuses on processes that add value• Helps us improve our way of doing work by

understanding the root causes of waste• A learning approach

– “Work as learning”– Not just process improvement

• Aligns the organization from top to bottom• Includes philosophy, people, problem-solving

Principles of the Toyota Way- Jeff Liker

14 Principles in 4 Categories • Philosophy (1)• Process (7)• People (3)• Problem solving (3)

Source: Liker: The Toyota Way

“Michigan Quality System” MQS Concept

• Create– a health system-wide – consistent approach – to quality and process improvement – adapting the principles of the Toyota Way– building on CQI base

• Incorporate 4 goals of Michigan Value :– Quality – Safety– Efficiency– Appropriateness

Perceived (and Real) Barriers to Application of Lean in Health

Care• (Add your barriers here)• • • • • • • •


Care• “Just the Management Flavor of the Month –

this too shall pass.”– Must show it is a learning approach, not just some projects

• “We’ve done well, why change?” “The autos had to do it”– Lack of a burning platform/overriding reason to change

(national v. personal)• “Let each unit choose QI process it finds most useful.”

– Some see no value in uniform QI approach; miss the synergy• “Who can lead this?”

– Lack of expertise/clinical champions • “I’ll join when I see that the leaders are on board.”

– If not led from the top, many will not engage• “How much are we spending on this new program?”

– Will the “return on time invested” be there?• “A 3 day workshop??!!”

– They’ll spend 3 days over 3 years and not change anything


Care• “Is this cost cutting disguised as QI?”

– The term Lean is misunderstood– 1990s CEP (Cost Effectiveness Program) = lay offs

• “I can’t do this on top of my day job.”– Isolated projects will not change the corporate culture –

it will never become management’s job• I can’t risk my area’s performance to optimize the

whole product line throughput– Accountability, teams, and incentives must cross silos

and levels of the organization– Evaluation of middle management must match corporate

goals – The Peace Health example

• “Creativity is our most important asset – standard work will stifle creativity.”– Can you innovate if you have not first standardized???– Do you want your cardiologist innovating or giving you

statins and aspirin?

Perceived (and Some Real?) Barriers to Application of Lean

in Health Care

OR,

People are not automobiles…

Michigan Quality System: The Value Proposition

• Uniform process improvement across UMHS – Across missions: education, research,

clinical/service• med students in clinic flow

– Across goals: - Quality - Efficiency- Safety - AppropriatenessA VSM created to improve “efficiency” can be used to improve

“safety” (root cause analysis following an adverse event)

– Spread to adjacent areas: merging projects• ED => Radiology => OR

– Training synergy• Transferability of training received for one project when

working on other projects

Model Line Projects

• What are they? Why use them? – Institutional examples of lean in

healthcare– Proof of concept at UMHS– Can expand upstream, downstream and

laterally• Why not train all managers first?

– We Learn Lean By Doing– Training long before use is less valuable– “Learn-do-reflect-discuss” cycle of a

learning organization

Model Line Sequence- through the 3 d workshop

phase• Vascular access – “Right line at the right

time”– Delayed discharge, cross silo (nursing,

MD, radiology)– Results: PICCs placed

•w/i 12h – up 43% •w/i 24h – up 40%•% needing Interventional Radiology

cut by 46%

Model Line Sequence- through the 3 d workshop

phase• Orthopedic consult – from request to scheduling

– Chronic problem, delayed appointments, frustrated referring physicians/patients/orthopedists

– Results: • Pre project process time = 27 min; waiting

time = 23 days• Post project MedSport = 89% of appointments

made on first call (2.5 min)• Radiation oncology scheduling and treatment

planning– Results:

• 54% treatment begins day of call (goal was 48h) for brain metastases

Model Line Sequence- through the workshop phase

• Orders Management Project (CPOE) – Medication management end-to-end– Redesign new workflow when

implementing new information technology

– High institutional visibility and impact

• Emergency Department – Patient flow (a series of projects for patient journey)

Model Line Sequence- through the workshop phase

• Operating Rooms– Sinus, otology (“decision to incision”)– Scheduling OR, missing consents, pre-

op, right site confirmation, delay in surgeon start

– Redesign before we move to new Ambulatory Surgery Center

• Faculty appointment, credentialing, insurance enrollment

• Care transition – Discharge planning, tracking before RV

Model Line Projectsunderway/planned

• Radiology and Lab – Misdirected results (ordering clinician does not receive report)

• Scheduled admissions• Wound care• CT scheduling and throughput• Institutional Review Board

ClinicED Radiology OR Admitting Transition Planning

PICC

A UMHS Patient

Patient Journey

ClinicED Radiology OR Admitting Transition Planning

PICC

Orders Management Project

UMHS Lean “Model Line” Projects

IdealPatientFlow

CT Scheduling and Reporting

OrthoScheduling

ENTCases

Vascular Access:Order to LinePlacement

Patient Journey

Care Transition

Wound Care

Misdirected Results

Sched.Admits

Determining Scope is Not Easy

– Emergency Department:• Idealized patient flow?• Chest pain patients?• Observation patients?• Patients needing CT scan or MRI?• Patients waiting for inpatient beds?• Patients needing consults?• Non-acute patients – in the wrong place?

– Operating Rooms• Admission Day Procedure patients?

– with one day length of stay (LOS)• All sinus surgery?

– Including clinic phase?• All cases to be moved to new ambulatory surgery

center?• Room turnover?

PICC order written in patient’s chart

PICC nurse travels to patient unit

Locate chart and confirm order

Locate and confirm patient

Notify patient of procedure

Obtain patient consent

Review labs & previous records for contraindications /

Assess need for PICC

Place PICC

Review VAS history. Review Care Web for meds, allergies, dx, care plan, location

Order CXR (includes order routing, transport, imaging, Radiologist read, MD request for adjustment )

Complete documentation in Mediserve and VAS web site.

VAS nurse

P/T:

W/T:FTQ: 100%

VAS nurse

P/T: 5 min

W/T: 1 min

FTQ: 100%

VAS nurse

P/T: 3 min

W/T: 2 min

FTQ: 80%

VAS nurse

P/T: 8 min

W/T: 0 min

FTQ: 90%

VAS nurse

P/T: 3 min

W/T: 1 min

FTQ: 85%

VAS nurse

P/T: 2 min

W/T: 0 min

FTQ: 93%

VAS nurse

P/T: 30 min

W/T:

FTQ: 78%

VAS nurse

P/T: 5 min

W/T:FTQ: 78%

VAS nurse

P/T: 5 min

W/T:

FTQ: 100%

VAS nurse

P/T: 2 min

W/T: 1 min

FTQ: 98%

To IR queueTo IR queue

To IR queue

Referral entered into VAS website

Results posted to VAS website

PICC Current State Map – V.A.S. (Part 1)

For patients with hx of IR

PICCs For patients with

inaccessible veins

PICC Nurse unable to

insert PICC

For PICCs requiring adjustment

14 hour delay if no order

4-14 hr delay if patient not

in room

4-18 hr delay if patient has concern

2-12 hr delay if patient won’t

consent

12-36 hr delay if change in

patient status or hold per

service request

5 min – 5 hrs

Up to 1 hr delay if at the end of VAS nurse shift, battery dies,

etc.

Up to 2 hr delay if tube lines full and can’t send

order

Total process

P/T: 63 min

W/T: 39-97 hr

FTQ: 34%

1. Determine that case should be referred to I.R. Set ‘transfer to IR flag’ on web

2. Complete transfer info in VAS web. Note any lab issues / sedation / …

3. Decide whether PICCs can be done today

4. When IR room becomes available, determine priority of patient for PICC

5. Contact Floor/unit to determine patient status & notify of time for PICC placement

6. Request transport via page (or SWAT via phone– only 7a-9p)

7. Patient arrives in IR holding area / IR room

9. PICC line placed.

VAS nurse

P/T:

W/T:

FTQ:

VAS nurse

P/T:

W/T:

FTQ:

Primary MD

P/T:

W/T:

FTQ:

Transport

P/T: 30 min

W/T:

FTQ:

PA / Fellow

P/T: 45-60 min

W/T:

FTQ:

Lead tech / RN

P/T: 1 min

W/T:

FTQ:

IR Lead tech

P/T: 2-5 min

W/T:

FTQ: 50%

IR Lead tech

P/T: 1 min

W/T:

FTQ:

From VAS queue

PICC Current State Map – I.R. (Part 2)

Results posted on VAS website

8. Obtain consent (pediatrics, if anesthesia needed)

Tech

P/T: 10-15 min

W/T:

FTQ:

Tech

10. Room turnover / clean up.

P/T: 20-30 min

W/T:

FTQ: 100%

Total process

P/T:

W/T:

FTQ:









Place PICC







PICC Brainstorms – V.A.S.


PICCs

For patients with

inaccessible veins


insert PICC

For PICCs requiring adjustment5 min – 5 hrs

To IR queue

Dr. order form should include what (diagnosis) pt is being treated for, what meds/ therapy & for how long

Have a VAS nurse available as a float to assist where needed prn…

VAS Web; link to radiologist, a.) to be a list for them of pts needing assessment of PICC placement, b.) to let them send result to VAS alert of needed adjustments or if PICC OK to use

VAS room for PICC placement; Modeled after current out patient program, which has proven to be both efficient & cost effective. (a.) pts would be scheduled, (b.) they would come to a clean, aseptic environment (vs. less than pristine room & bed…= decreased infection rate). (c.) line is placed, checked, adjusted if needed all in one time frame/ visit. (d.) when pr returns to floor line is ready for use. (e.) PICC nurse would still work floors, especially ICUs for pts unable to be scheduled in “VAS PICC Clinic”

Get rid of d/c pending

Have one dedicated to dc pending person & another for pending work

On VAS website let MD know PICC is done

Have the VAS website order = physician order

Just take the laptop & go (not enough laptops – people individually resistant to change)

Have someone from central dispatching call the floor clerk to ensure order is in place

Have a lesser skilled person go ahead and scout out these things before the skilled PICC nurse arrives

VAS website to have MD attest to order in chart

VAS website info (absolute & relative contraindications)

Bedside side should be always be assessed & not auto-referred to Angio unless pts name is recognized

Scout person

Have the frequent flyer patients looked at first to get them off the list

Angio won’t place line if INR > 2

Look into what cut-off is for INR

CDC guidelines on infection

Have a lesser skilled person go ahead

Have floor nurses be aware & coordinate pts’ appointments

PICC nurses work on 1 floor at a time

Schedule pts and have pts come to you

Central scheduling online so people can see where pt is going (perhaps with CPOE) – 6A especially gone to PT/OT

RN, MD, clerk on floor give pt a handout on PICC line placement and have pt or guardian initial paper

Scout person

Was the patient informed to start? (In ICU it’s inferred)

Maybe have 2nd VAS website PICC nurse info page to get consent in advance

Sometimes physician can get consent

VAS to have access to look at digitized cxr, like a monitor in our office so we can access cxr to visualize malpositioned lines to decide appropriate adjustment

Minimize ping-pong effect

Navion study magnet guided light tract – there’s a flip side that sometimes it needs to be adjusted

What % is re-adjusted?

Have ready supply carts / trays (model = Anesthesiology trays are all the same)

Schedule pts to come into the PICC nurse so pt is all ready to go at that time. Model from outpatient. But someone needs to have the prepared material, order, consent, labs, etc.

Establish need for PICC

Physician

P/T: 15 min

W/T: 30 minFTQ: 100%


PICC Future State Map TOTAL PROCESSVAS only w/ IR

P/T: 165-170 min 260-275 min

W/T: 7-10 hr 8.5-11.5 hr

FTQ: 88% 86%

Write / place PICC order

Check order & schedule. Confirm on VAS website

Physician

P/T: 5 min


Asst. Personnel

P/T: 45 min

W/T: 1-4 hrFTQ: 98%

Assess / place PICC line. Complete documentation

VAS Nurse

P/T: 60 min


Order chest x-ray (fax order, copy made by CXR)

VAS Nurse

P/T: 5 min

W/T: 5 minFTQ: 100%

Contact floor clerk to schedule

X-ray clerk

P/T: 5 min

W/T: --FTQ: 100%

Transport patient to CXR

Pt transport

P/T: 10-15 min

W/T: 5 minFTQ: 100%

X-Ray digitally completed

X-ray tech

P/T: 10 min

W/T: ---FTQ: 100%

Page PICC to adjust as necessary

1700 RadP/T: 10 min

W/T: 30 minFTQ: 90%

Check website 3 times daily

Lead tech

P/T: 5 min

W/T: --FTQ: 100%

Contact floor clerk to schedule into designated slots

IR clerk

P/T: 10-15 min

W/T: --FTQ: 100%

Clerk completes check-off list

IR clerk

P/T: --

W/T: --FTQ: 100%

Talk with floor nurse re: patient status

IR Nurse

P/T: 10 min

W/T: 30 minFTQ: 90%

Transport patient to IR

Pt transport

P/T: 10-15 min

W/T: 5 minFTQ: 100%


IR PA / fellow

P/T: 60 min

W/T: 10 minFTQ: 98%


VAS notified

VAS RN

notified

Assessment

Patient education

General PICC consent, incl.

Fluoro

Narrow criteria at onset

RL / RT Standard orders

E-signature

Error-proofing

order

Pre-program fax #

VAST education for

access

Phys AssistantDedicated Lead-lined PICC room

Increase current room utilization

hours

OR / Procedure checklist

W/T: 60 min W/T:

45 minW/T: 5-10 min

W/T: 2 hr

W/T: 10 min

W/T: 30 min

W/T: 5 min

W/T: 15 min

W/T: 30 min

Current State Value Stream MapInternal Medicine Clinic

General Medicine Outpatient

WaitingRm

ExamRm

3/23/2005

Patient

Page 1

PatientClinicPhysician

Scheduled Appointment

SchedulingSystem

EWS

Daily Schedule

ICheck

intoClinic

Clerk

Front Desk

Printforms &labels

ClerkFront Desk

Checkvitals &blood

pressure

MACentral OR

Checkout ofClinic

Clerk

Front Desk

FinalizePlan

HO

Exam Rm

StaffCase

HOStaff Rm

Attending

Fill outRequisi-

tionForm

HO

Exam Rm

PhysicianVisit

HO

Exam Rm

IPostRouter

MA

Staff Rm

Place Ptin Room

MAExam Rm

MA & PtMA & Pt MA HO HO HO +/-Attending

Patient

Called in Appt

Next RV Appt

Prof BillingSystem

IDX

Billing

Router, Labels,PSL, Pt Notes

RequisitionForm

RequisitionForm

6 HO & 2 Attending each shift (½ day)5 RV + 1 NP per HO per shift

1 RV / 30 min1 NP / 60 min

Router Form

P/T= 2 minW/T=R/T=FTQ= 99%



P/T= 1 minW/T=R/T=FTQ=100%

P/T= 1 minW/T=R/T=FTQ=100%

P/T=15 minW/T=R/T=FTQ=100%





Forms & Empty Rm

2 min 2 min

20 min 1 min

3 min

2 min

2 min

1 min

1 min

10 min 1 min

15 min 2 min

2 min

10 min

1 min

10 min

2 min

5 min

My Inbox

CareWeb

IN

Printed Hard Copies

ReviewResults

HOClinic

Patient

Communicatewith

Patient

MAClinic

DevelopPlan

HOClinic

QUEUE

Pt Notification

Post or E-Mail

3/23/2005

Page 2

Fax

Tubed

CollectResults

MA

Office

P/T= minW/T=R/T=FTQ=%

OrganizeResults

HO

Staff Rm




Application Folder

I

I

I

I

Current State Value Stream MapInternal Medicine Clinic

General Medicine Outpatient

Pathology

Pathnet

Radiology

RIS

Tot =

Tot =

I I


Orthopaedics MedSport Current State Map

Wednesday March 16, 2005 - Page 1

D R A F T - Orthopaedic Surgery MedSport - Current State Map

Summary

Total Processing Time : 11 31 minutes

Total Waiting Time: 1 - 36 days

% Complete and Accurate: %

Metrics

P/T: Processing Time

W/T: Wait Time

% C & A: % Complete and Accurate

Wait time (day)

Process Time (sec)

Mapping Icons

In

~~~ Service

Patient

Ref. Phys.Pt / ATC

Data Box

Information

OutsideSource

In Box(Queue)

ProcessStep

Wait Time

Mail

Phone

Fax

Email

5 min 10 min

0 - 3 d0 - 1 d

P/T: 5 min

W/T: 0-3 days

C&A: 100%

Call Ctr.

In

~~~Receipt &InspectRequest

P/T: 1 min

W/T: 0 days

C&A: 98%

Physician

In

~~~ClinicalReview

P/T: 3 min

W/T:0-3 days

C&A: 100%

Call Ctr. Sctry.

In

~~~TransportAppointment

Request

P/T: 2 min

W/T: 0-3 days

C&A: 95%

Ref. Coord.

In

~~~Business/ClinicalReview

P/T: 10 min

W/T: 0-14 days

C&A: 5%

Call Ctr.

In

~~~Re-workRequest

P/T: 1 min

W/T: 0 days

C&A: 98%

Ref. Coord.

In

~~~Denial/PriorSetting

P/T: 3 min

W/T: 0 days

C&A: 100%

Sctry.

In

~~~TransportAppointment

Request

P/T: 1 min

W/T: 0-1 days

C&A: 100%

Front Desk

Mail Itinary

P/T: 5 min

W/T: 0-1 days

C&A: 100%

Call Ctr.

In

~~~Scheduleand/or Notify

6 Requests28 Requests 6 Requests 6 Requests 28 Requests 30 Requests 29 Requests

1 - 14 d0 - 1 d

2 min

0 - 1 d0 - 3 d

3 min

0 - 1 d1 - 7 d

1 min

0 - 1 d

3 min

0 - 1 d

1 min

0 - 1 d

5 min

0 - 1 d0 - 1 d

1 min

0 - 1 d

Appeals

2 Rqsts2 Rqsts

Requests 30/Day

OPNotes

PhysicianNotes

Imaging

2 Rqsts

Lost Req1 Req

Orthopaedics Taubman Current State Map

Wednesday March 16, 2005 - Page 1

D R A F T - Orthopaedic Surgery Taubman Center (Adult) - Current State Map

Summary

Total Processing Time : 10 - 58 min (Avg. 34 min)

Total Waiting Time: 4 - 60 days (Avg. 32 days)

% Complete and Accurate: 44%

Fax

Phone

Email fromPatient

Referral SnailMail

Email fromPhysician

Walk-in

5%

10%

20%

53%

5%

7%

In

~~~

Receipt EachPhysician’sSecretary

ReceiptMedSport

Receipt S.Main

ReceiptTaubman

Receipt of Request

P/T: 3 sec - 2 min

W/T: 1 - 7 days

C&A: 95%

65/Day

InspectionRole

P/T: 5 min

W/T: 1 - 5 days

C&A: 80% RequestsCompleted

Metrics


W/T: Wait Time


Wait time (day)

4

62

3

Process Time (sec)

Mapping Icons

In

~~~

Payer

Imaging

Other AuxlServices

Inspection of Requestfor Completeness,

Payer Appropriateness,Demographics, Clinical

Info.

Triage toServices

P/T: 1 min

W/T: 1 day

C&A: 100%Distributed toServices

PhysicianReview &

Decision toSee

In

~~~In

~~~

15% re-triaged

Tumor

Trauma

Spine

MedSportNon-Op

MedSport

Joints

Hand/Arm

Foot/Ankle

P/T: 1 - 40 min

W/T: 0 - 21 day

C&A: 85%AppropriatelyDistributed

AppointmentScheduling w/

Discourse

AppointmentScheduling

Input

P/T: 1 - 5 min

W/T: 1 - 21 day

C&A: 95% ActuallyScheduled

Service

85% of Peds &10% of Adults

YES 90%Who

WhereWhen

NotificationEmail

NotificationPhone

UMHSPhyisician

Patient

ExternalPhysician

Intra-Dpt.

OutsideOrtho

E D

UMHSPhyisician

Patient

ExternalPhysician

Intra-Dpt.

OutsideOrtho

E D

NotificationMail

P/T: 2 - 5 min

W/T: 0 - 5 day

C&A: 80%Satisfaction w/Time& Date

In

~~~

Denial to See10%

Data Box

Information

OutsideSource

In Box(Queue)

ProcessStep

Wait Time

300

1

60

10.5

1,230

11

180

2.5

210

20% of scheduledappointments areunaccepable to

patient. Rescheduled

Orthopaedics Future State Map

Thursday March 17, 2005 - Page 1

D R A F T - Orthopaedic Surgery - Future State Map

Summary

Fast Track Slow Track

Total Processing Time : 6- 11 min 8 - 13 min

Total Waiting Time: 0 - 1 min 1 - 7 days

Lead Time: 6 - 12 min 1 - 7 days

% Complete and Accurate: 95% 85%

Metrics


W/T: Wait Time


ConsultRequest

Guidelines onthe Web

BusinessReview

Ref. Phys.

OutsideOrtho

OPNotesED

Patient

Phone

Input byphone only.Faxes and

emails will befunneled to

phoneprocess

Clinic ReviewSchedule

AppointmentAppointment

Requirements

ItineraryPrinted &

Mailed

Entry Criteria

||||||||||||||||||||||||||||

Call Center Staff

Contact Schedule ReminderScheduling Patient Appointment:

StandardWork

3-5 Days Pre-Arrival Call

StandardWork

PatientRef. Phys.Pt / ATC

90%

LL

FailedRequests

areRedirected

Fast Track

2nd ReviewRotatingDesignee

10%

Slow Track - Exception Process

P/T: 6 - 11 min

W/T: 0 -1 min

C&A: 95%

P/T: 8 - 13 min

W/T: 1 - 7 days

C&A: 85%

Fast Track Slow Track

Mapping Icons

In

~~~ Service

Data Box

Information

OutsideSource

In Box(Queue)

ProcessStep

Wait Time LLLearningLoop

MQS Training Development

• Goal: Build training for wide application of lean thinking to projects and daily problem solving in UMHS

• Levels: – General awareness: orientation, new manager, senior

manager– Just In Time: Team member – Coach training through graded responsibility, tool training

• Long Term Goal: – Managers understand their job is to optimize the value

stream map of their product line– Employees understand their job is to identify immediately

when something goes wrong and help solve the root cause

Issues for Discussion How do we…

• create a blame-free, responsible culture - to learn from every error, every day?

• get all to use the same tools for QI?• coordinate improvement efforts?• move beyond “projects” to “every day”?• choose where to start?

• Are patients are interested?• What is the leader’s role in a Lean

Organization?

Issue: blame free culture

Where there is an error, there is the opportunity to learn and improve. – Learn from every error, every day– How to create a blame-free, responsible

enterprise? – The 5 why’s, not the 5 who’s– “The goal is prevention”. Jim Bajian, VA

Chief of Patient Safety– Respect the workers: thanks for what

you’ve done

Issue: one improvement model

How do you encourage wide acceptance of one philosophy and set of tools for quality and process improvement to allow synergy across projects?– Cross-silo or cross-department improvement– Value Stream Map for improved efficiency also can

be used to improve patient safety– Med Education projects in clinical areas– “Clinical research – clinical flow” interface

• A Learning Approach, not just a process improvement model

• 4P Model (Jeff Liker)– Problem solving– People and partners– Process– Philosophy

Issue: coordinate improvement

How best to coordinate across your groups with Process Improvement expertise and resources?

For example, UMHS has:– CQIP (Hospital’s QI program)– Program and Operations Analysis– Chief of Staff office/Safety/Risk

Management– Faculty Group Practice– Ambulatory Care– Departmental expertise– Health Services Research faculty

Issue: beyond “projects” to every day

“Value stream improvement is management’s responsibility”. (Rother & Shook)

How can you facilitate “value stream management” as the way that managers view their role?

• Value Stream Map high level product lines• “Projects” merge into daily management• Require current and future state value stream

maps for all capital, IT, space requests– Park Nicollet: no request for resources without proof

of working at tact time, leveling, and other TPS metrics

• Embed facilitators in units (1-3% of workforce?)

Issue: where to start?

• Do we start at top (leaders), at middle (middle management), or at bottom (front line workers)? – Wherever you start, the problem will be at another level.– Plan on all levels

• Do you change culture first or do projects first?– “Easier to act your way to a new way of thinking than to

think your way to a new way of acting” (John Shook) – “Culture = education, training, rewards” (Jeff Liker)– Culture arises from management reacting to

actions/behaviors– Are learners or risk-takers rewarded, encouraged,

tolerated, or discouraged?– Are silo-protectors rewarded, encouraged, tolerated, or

discouraged?

Issue: are patients ready?

• Will the public flock to high reliability health care as they have to high reliability auto manufacturers? (like JD Power)

• Can we guarantee that no one loses his/her job as we improve?– “Transforming waste into value”

• v. “Eliminating waste”• High market demand – expert staff shortage

– “No job loss” commitment essential to Lean• Who would create a Future State Value Stream Map

with their job eliminated?• Requires management of personnel issues first

Lean Transformation“Management has to understand that its role

is to see the overall flow, develop a vision of an improved, lean flow for the future and lead its implementation. You can’t delegate it. You can ask the front line to work on eliminating waste but only management has the perspective to see the total flow as it cuts across departmental and functional boundaries”.

Learning to See. Rother and Shook

• Leader as - Problem Solver- Teacher - Servant- Mentor - Coach

Thoughts and Feedback?

• • • •

Additional Materials

• Some Lean terms• References• Liker’s 14 Principles of the Toyota Way• UMHS Model Line Project selection

process and steps• Value Stream Mapping information• Waste categories• Full report on one model line project

(PICC)

Lean Terms

• Jidoka – designed not to pass on a defect; really “machines working for people”

• Poka-yoke – error proofing – forcing functions of built-in quality, designed not to build a defect

• JIT – Just In Time, for pull systems• Andon Cord – to correct the error and its root cause

in real time; if needed, to “stop the line”• Andon Board – tracks “down time” by cause• Kaizen – continuous improvement, or “burst”• Sensei – teacher or master• Muda – waste • Muri – waste of stress, leads to Karoshi (death from

overwork)• Heijunka – leveling the workload • Kanban – signal for pulling work

References

• UMHS Lean Website: www.med.umich.edu/i/mqs• Liker J. The Toyota Way.• Womack J and Jones D. Lean Thinking.• Rother M and Shook J. Learning to See.• Marchwinski C and Shook J, eds. Lean Lexicon.• Spear S. Fixing Health Care from the Inside, Today.

Harvard Business Review. Sept 2005• Spear S. Learning to Lead at Toyota. Harvard

Business Review. May 2004 • Spear S, et al. Decoding the DNA of the Toyota

Production System. Harvard Business Review. Sept 1999

14 Principles of the Toyota WayCan Work in Healthcare

14 Principles in 4 Major Categories • Philosophy• Process• People• Problem solving


Principles of the Toyota Way

• Philosophy– Base management decisions on long

term philosophy, even at the expense of short term goals• Generate value for the customer, society,

and economy



• Process– Create continuous flow to surface

problems– Use pull to avoid overproduction– Level the workload (heijunka)– Build the culture of stopping to fix

problems, quality right the first time• Machines serving people (jidoka)• Signals for stopped flow (andon)



• Process, continued– Make standard work

• If an improvement works, make it the new std

– Use visual controls so no problems are hidden

– Use only reliable, thoroughly tested technology that serves your people and processes



• People– Grow leaders that understand the work,

live the philosophy, and teach it to others

– Develop exceptional people and teams who follow the philosophy

– Respect extended network and challenge suppliers to improve



• Problem solving– Go and see (the workplace - gemba)

• Solve problems by going to the source to personally observe and verify data

– Make decisions slowly, by consensus; implement rapidly• Discuss with all affected people

(nemawashi)

– Become a learning organization through relentless reflection (hansei) and continuous improvement (kaizen)


Model Line ProjectSelection Process

Criteria:• Institutional priority/visibility• Potential for creating an exemplar • Opportunity to expand upstream,

downstream, sideways • Opportunity for improvement – gaps

– access/waits/bottlenecks, financial, satisfaction, errors

• Process dependence• Existence of a “clinical champion”• A defined process, with a start and stop, and

an owner. It has SIPOC– Suppliers, Inputs, Process, Outputs, and

Customers

Model Line ProjectSelection Process

Selection:• Selection of Areas:

– Prioritization Committee (hospital COO, CFO, CON, COS; FGP Exec Med Dir)

• Project leads: Determine scope, participants and timing

• Decision panel: All the leaders who need to approve the Future State Value Stream Map

Model Line Project Flow• Select area: institution leaders (CEOs, COOs)• Select project leads: MQS leaders• Determine actual project, scope, team

members, timing: Project Leads• Pre workshop scoping: Project Leads,

facilitators• Three day workshop model (one of many options)

– Day 1: Decision Panel charge, learn Lean & Current State Value

Stream Map on their data– Day 2: Future State Value Stream Map,

Decision Panel approval– Day 3: Implementation plan, barriers,

Decision Panel approval

Learning to Seeby Rother and

Shooka guide to value stream mapping

Using the Value Stream Mapping Tool

Understanding how things currently operate. This is the foundation for the future state

Value Stream Scope

Designing a lean flow through the application of lean principles

Current State Drawing

Implementation Plan

Determine the Value Stream to be improved

The goal of mapping! Implementation of Improved Plan

Future State Drawing

Developing a detailed plan of implementation to support objectives (what, who, when)

Sta

nd

ard

ize

for

late

r im

pro

vem

ent

From John Long

Value Stream Mapping

• Make work visible• Understand work flow• Measure process performance in terms of

cost, service, and quality• Redesign process to meet specific

business objectives• Use Lean tools to achieve the redesigned

process

Drawing a Value Stream Map to

Achieve Future State Goals • Is process-time too long? • Is wait-time too long? • Is lead-time (process plus wait-time) too long?

– Can each be reduced? – If so, by how much? – How would you draw your map to meet this time

goal?

• Is overall quality (% complete and accurate) acceptable? Is there too much rework?– Can quality be improved and rework reduced? – If so, by how much? – How would you draw your map to meet this future

state goal?

Source: John Long, M.D., Lean Concepts, LLC

Future State Design Questions

• What are customer requirements? • Where and how will you trigger or

sequence work? • How will you establish rhythm or

milestones to pace the work (pitch)?• How will you make work flow smoothly? • How will you make work progress,

delays, and problems visible? • What process improvements are

necessary?


Waste in Health Care ImpactsQuality, Safety, Efficiency &

AppropriatenessQuality and

Safety• Defects in

products

Appropriateness

• Design of goods and services which do not meet users’ needs

Efficiency• Overproduction of goods • Inventories of goods awaiting

future processing or consumption

• Unnecessary movement of people

• Overprocessing• Unnecessary transport of goods• Waiting

(for process equipment to finish or on an upstream activity)

Eight Types of Waste in Heath Care

Waste Category

Definition Heath Care Examples

Correction Rework because of defects, low quality, errors.

Requisition form incomplete/inaccurate/illegible.Order entry error.

Overproduction Producing more, sooner, or faster than required by the next process.Inappropriate production.

Unused printed results/reports.Unnecessary labs/visit.

Motion Unnecessary staff movement (travel, searching, walking).

Walking to and from copier/office/ exam room. Searching for misplaced form/ equipment/chart.

Material Movement

Unnecessary patient or material movement.

Multiple patient/paperwork transfers.Temporary locations for supplies.

Waiting People, machine, and information idle time.

Patient in waiting room. Wait for lab results.

Inventory Information, material, or patient in queue or stock.

Patient waiting in exam room. Excess stored supplies.

Processing Redundant or unnecessary processing. Reentry of patient demographics. Repeat collection of data.

Underutilization Underutilized abilities of people. Nurses refilling Rx or making appointments.Doctors doing simple patient education.

From Elsa Mersereau

TYPES TYPES OFOF

WASTEWASTE

II

CC

OO

MMWW

PP

MM

CURRENTTHINKING

WASTE NOT DEFINEDREACT TO LARGE EXAMPLES

REACTIVE IMPROVEMENT

REQUIRED THINKING

CONTINUOUS IMPROVEMENT

CorrectionCorrection

OverProduction

OverProduction

MotionMotion

MaterialMovementMaterial

Movement

WaitingWaiting

InventoryInventory

ProcessingProcessing

WASTE IS "TANGIBLE"IDENTIFY MANY SMALL OPPORTUNITIES

LEADS TO LARGE OVERALL CHANGE

GM’s Categorization of Waste

WASTEWASTE

Unreasonable-ness

Unreasonable-ness

UnevennessUnevenness

Source: GMS Training

Waste in the Current State: Causes and

CountermeasuresType of Waste

Cause(s) Countermeasure

Correction of defects and rework

Procedure information incomplete or inaccurate; 20% of scheduled, authorized procedures cancelled or rescheduled

Reduce lead-time to eliminate rescheduled or cancelled procedure (no-shows only)

Inventory Backlog of schedule, authorized procedures

Reduce wait-time.

Over-processing

Process time too long; scheduling and authorization not coupled

One-piece flow

Over-production

Procedures scheduled weeks or months in advance

Reduce lead-time to 3 days or less.

Waiting Payer authorization too slow and days after scheduling

Reduce process and wait time for pending process; 24 hr. in-patient insurance informationFrom John Long

Lean Culture Transformation

Management owns the Vision

Operators own the Vision

Learning &Launch

GoalsCommitmentLean Training

Value Stream Mapping

Current state mapFuture state map

Implementation (Kaizen Plan)

ObjectivesMethodsResponsibilitiesTimelinesReviews/checks

LeanWorkshops

Lean team trainingWorkplace organizationFlexible operations Standard/balanced workBuilt-in-qualityPull systems Load leveling


Issues for Discussion

What is optimal coordination model/location within a health system for:– Ongoing training – Project management

• Selection, assignment of facilitator/coach, actual day-to-day management and coordination (especially for cross-silo projects)

• Decentralized? Give them the training and get out of the way – Departmental initiatives – Line Managers

• Troubleshoot overlapping projects – Two groups working on misdirected lab results – Lean and 6 Sigma for prescription security problem

Lean PICC Project

Jackie LapinskiSr. Management Engineer

Program & Operations Analysis

PICC Line Overview

• Special intravenous (IV) catheter used when IV therapy or antibiotics are administered for a long period of time

• Inserted primarily by Vascular Access Services nurses, at the patient’s bedside

Why Improve the PICC Line Process?

• Provide high quality patient care

• Maximize resource utilization

• Reduce long lead times

• Manage growth in volume

Purpose Statement

Streamline the PICC process end to

end in order to provide the highest

quality and efficient patient care by

providing the right line at the right

time within 24 hours of the order (or

VAS referral, for IR PICCs).

Where’s the Waste?

• Discrepancies between paper order and referral

• Pending discharge PICC orders receive priority

• Discrepancies in patient location• Patient preparedness• Delays in chest x-ray process• Lack of standardized IR scheduling

process• Lack of standardized consent

documentation

Project Schedule• Scoping session and pre-work

– SIPOC – In & out of scope– Identify participants

• 2-Day Workshop– Confirm current state– Develop future state– Develop implementation plan

• Reviews with leadership– 30, 60, 90 day post-workshop

• Ongoing monthly updates

Current State Map – VAS









Place PICC




VAS nurse

P/T:

W/T:FTQ: 100%

VAS nurse

P/T: 5 min

W/T: 1 min

FTQ: 100%

VAS nurse

P/T: 3 min

W/T: 2 min

FTQ: 80%

VAS nurse

P/T: 8 min

W/T: 0 min

FTQ: 90%

VAS nurse

P/T: 3 min

W/T: 1 min

FTQ: 85%

VAS nurse

P/T: 2 min

W/T: 0 min

FTQ: 93%

VAS nurse

P/T: 30 min

W/T:

FTQ: 78%

VAS nurse

P/T: 5 min

W/T:FTQ: 78%

VAS nurse

P/T: 5 min

W/T:

FTQ: 100%

VAS nurse

P/T: 2 min

W/T: 1 min

FTQ: 98%


To IR queue




PICCs For patients with

inaccessible veins


insert PICC


14 hour delay if no order

4-14 hr delay if patient not

in room

4-18 hr delay if patient has concern

2-12 hr delay if patient won’t

consent

12-36 hr delay if change in

patient status or hold per

service request

5 min – 5 hrs

Up to 1 hr delay if at the end of VAS nurse shift, battery dies,

etc.

Up to 2 hr delay if tube lines full and can’t send

order

Total process

P/T: 63 min

W/T: 39-97 hr

FTQ: 34%

Current State - BrainstormsPICC order written in patient’s chart








Place PICC








PICCs

For patients with

inaccessible veins


insert PICC

For PICCs requiring adjustment5 min – 5 hrs

To IR queue

Dr. order form should include what (diagnosis) pt is being treated for, what meds/ therapy & for how long

Have a VAS nurse available as a float to assist where needed prn…

VAS Web; link to radiologist, a.) to be a list for them of pts needing assessment of PICC placement, b.) to let them send result to VAS alert of needed adjustments or if PICC OK to use

VAS room for PICC placement;

VAS to have access to look at digitized cxr, like a monitor in our office so we can access cxr to visualize malpositioned lines to decide appropriate adjustment

Just take the laptop & go(not enough laptops -people individuallyresistant to change)

Get rid of D/C pending

Have one dedicated toDC Pending person &another for pendingwork

On VAS website let MDknow they have done it

Have the VAS websiteorder be = physicianorder per HospitalAdministration

Schedule pts andhave pts come to you

PICC nurses work on1 floor at a time

Have floor nurses beaware & coordinatepts’ appointments

Have a lesser skilledperson go ahead

Central schedulingonline so that peoplecan see where pt isgoing away (perhapswith CPOE) - 6Aespecially - gone toPT/OT

RN, MD, clerk onfloor give pt ahandout on PICCline placement andhave pt or guardianto initial

Scout person

Was the patient informedto start?

In ICU, it’s inferred

Maybe have a 2nd VASwebsite PICC nurse infopage to get consent inadvance

Sometimes physician canget consent

Scout person

Have the frequentflyer patients lookedat first to get them offthe list

Angio won’t place lineif INR > 2

Look into what thecut-off is, if there isone, if IRN is

CDC guidelines oninfection

VAS website info(absolutecontraindications,relativecontraindications)

Bedside side shouldbe always assessed& not auto-referredto Angio unless ptsname is recognized

VAS website tohave MD attestto it

Have someonefrom centraldispatching call thefloor clerk toensure order is inplace

Have a lesserskilled persongo ahead andscout out thesethings beforethe skilled PICCnurse arrrives

Have ready supply carts / trays (model =Andesthesiology trays are all the same)

Schedule pts to come in to the PICC nurse so thatpt is all ready to go at that time. Model fromoutpatient. But someone needs to have theprepared material, order, consent, labs, etc.

Minimize ping-pong effect

Navion study magnetguided light tract there’sa flip slide thatsometimes it needs tobe adjusted (see dataTBD)

What % is re-adjusted?

Future State Map - VAS

Establish need for PICC

Physician

P/T: 15 min



TOTAL PROCESSVAS only w/ IR

P/T: 165-170 min 260-275 min

W/T: 7-10 hr 8.5 – 11.5 hrs

FTQ: 88% 86%

Write / place PICC order

Check order & schedule. Confirm on VAS website

Physician

P/T: 5 min


Asst. Personnel

P/T: 45 min

W/T: 1-4 hrFTQ: 98%


VAS Nurse

P/T: 60 min


Order chest x-ray (fax order, copy made by CXR)

VAS Nurse

P/T: 5 min

W/T: 5 minFTQ: 100%

Contact floor clerk to schedule

X-ray clerk

P/T: 5 min

W/T: --FTQ: 100%

Transport patient to CXR

Pt transport

P/T: 10-15 min

W/T: 5 minFTQ: 100%

X-Ray digitally completed

X-ray tech

P/T: 10 min

W/T: ---FTQ: 100%

Page PICC to adjust as necessary

1700 RadP/T: 10 min

W/T: 30 minFTQ: 90%

Check website 3 times daily

Lead tech

P/T: 5 min

W/T: --FTQ: 100%

Contact floor clerk to schedule into designated slots

IR clerk

P/T: 10-15 min

W/T: --FTQ: 100%

Clerk completes check-off list

IR clerk

P/T: --

W/T: --FTQ: 100%

Talk with floor nurse re: patient status

IR Nurse

P/T: 10 min

W/T: 30 minFTQ: 90%

Transport patient to IR

Pt transport

P/T: 10-15 min

W/T: 5 minFTQ: 100%


IR PA / fellow

P/T: 60 min

W/T: 10 minFTQ: 98%


VAS notified

VAS RN

notified

Assessment

Patient education

General PICC consent, incl.

Fluoro

Narrow criteria at onset

RL / RT Standard orders

E-signature

Error-proofing

order

Pre-program fax #

VAST education for

access

Phys AssistantDedicated Lead-lined PICC room

Increase current room utilization

hours

OR / Procedure checklist

W/T: 60 min W/T:

45 minW/T: 5-10 min

W/T: 2 hr

W/T: 10 min

W/T: 30 min

W/T: 5 min

W/T: 15 min

W/T: 30 min

• Level schedule with designated slots for PICC placement in radiology with no bumping

• Assistive personnel ensuring completion of written order, labs, scheduling patient prior to PICC nurse traveling to the bedside

• Potential to use the electronic referral as the legal order (using e-signature)

• Potential process change to close the loop on PICC adjusts by routing that information through the VAS department, rather than the ordering physician

Bold Moves

Metric Current Estimate

From Current

State Map

Target from Future State

Map

Actual(post

implementation)60 Days

Process Time

75 minutes 166 165 min

Wait Time 24.75 hours 39-97 hr 7-10 hr

Lead TimeAvg. 26 hrs (max 290 hrs)

1-98 hr 10-13 hr Avg 16.6 hrs

FTQ 34% 34% 88%

% < 12 hours

43% 43% 85% 58%

% < 24 hours

61% 61% 100% 75%

Performance Metrics - VAS

Metric

Current Estimate

From Current

State Map

Target from Future State

Map

Actual(post

implementation)60 Days

Process Time

120 minutes 120 minutes 4.3 – 4.6 hr

Wait Time 62.5 hours 62.5 hours 8.5-11.5 hr

Lead Time64.5 hrs (392 hrs max)

64.5 hrs 4.5-15 hr Avg 42.6

FTQ 86%

% < 12 hrs (of referral from VAS)

23% 23% 85% 26%

% < 24 hrs (of referral from VAS)

49% 49% 100% 52%

Performance Metrics - I.R.

Documents

Application of Lean Thinking to Health Care Development of the “Michigan Quality System” at the U of M Health System John E. Billi, M.D. Associate Dean