Lean And Six-Sigma With Workload Data 1 Copyright © 2009 GRASP® Systems International Companies

Lean And

Six-Sigma With

Workload Data

1Copyright © 2009 GRASP® Systems International Companies

Goal

Give to patients;Exactly what they need;

When they need it;Every time;Defect free;

In a safe environment;At the lowest cost;

Without waste.


3

Objectives

Understand how the tenants of LEAN technology can help with improving patient care and patient outcomes

Appreciate the role of workload in LEAN simulation modeling

Identify 3 sources of information for potential study using LEAN and workload

Understand how LEAN and workload were able to predict error reductions using medical bar coding technology

Copyright © 2009 GRASP® Systems International Companies

4

“Lean” Methodology (TPS)

Started from need

Absolute elimination of waste

Support needed Flow process Automation (Human Touch)

The “Criticals” Information Team work Individual Skill


5

A bit more about “Lean”

Analysis of “Waste” Time on hand (waiting) Transportation (Patient and Staff Delay) Processing (Materials – workflow) Movement “Do overs”

Understand the work

Ask Why 5 times


6

Why Hospitals are moving to TPS

Improve Patient Outcome(s)

Decrease Cost

Respond to Increase Demand

Enhance Patients dealing with chronic disease

Address technology implementation processes and applications

Address specialization and fragmentation of hospital care


7

Where to begin?

Troublesome processes Bottle necks Complaints (Patients and Staff)

Suggestions from Staff

Suggestion from Patients

Observations

Outcome data


8

Nursing Practice Time

Patient Care Activities 81 min

Assessment (Vital Signs)31 min

Care Coordination 86 min

Documentation 148 min

Medication Administration 72 min

Source: JONA Vol 39, No 6, June 2009

Notes: 36 Hospital Medical-Surgical Units in 17 health care systems and 15 states

Waste Non ClinicalWalking Personal TimeLooking/Retrieving Patient/Family CareDelivering Administration/Teaching


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Processing Information

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Human information processing deals with how people receive, store, integrate , retrieve and use information

Capacity is about 5-7 chunks of discrete information

Bottle necks occur and storage is an issue

The human capacity to interpret accurately the structure and dynamics of complex systems is grossly overestimated


1010

Complexity(Multiple States)

Example: Medication Administration

Complex Systems are multi-dimensional!From: “Driving Improvement in Patient Care.”


11

Enablers

What Assists in representing essential aspects of an existing system


12

Another Enabler is Workload Data

For Example in Process Improvement




15

Challenges in Data Acquisition

What is the distribution of times that it takes to perform the individual tasks in a process?

Time and motion studiesStandardized timesElectronic health record digital dataExpert opinionTheoretical time distribution curvesWorkload Time Standards



17

So from the “Lean” with IT Perspective in Performance Improvement Activities we:

Combine duplicate activities

Eliminate multiple reviews and approvals

Automate repetitive tasks

Simplify complex activities

Reduce batch sizes

Reduce amount of handling

Process in parallel

Error-proof activities

Implement demand pull (build to orders)

Outsource inefficient activities


18

So the Question is…

Is there a significant difference

in nursing hours

cycle time for medication administration

cost&

of course medication errors

after implementation of Bar Code Medication Administration


19

Examine the current state


20

Where to look for Workload

Analytical Phase


21

What do we want to occur?

Improvement in medication error per intervention

Decrease in cycle time per intervention than the paper process

Increase in productivity (decrease in time) i.e., nursing labor hours per intervention

Decrease in total cost per intervention (medication error savings)

What is the difference between the cost of the investment and the return?


22

Let’s examine the steps

The intervention

The steps that are part of the intervention Check medication administration record Prepare medication Administer medication as per protocol Document

Total time for the process is 38.8 minutes (Included is fatigue and delay and adjustment for things we haven’t accounted for)


23

A word about simulation

We can test our hypothesis without actually implementing it

We can examine the steps to determine where the bar coding fits

Delineate the steps with bar coding

What is the return on investment?

Actually determine amount of time saved

Actually determine amount saved by decreasing error rate by 50%


24

Check the Actual Results

Bar Code Administration does not take longer than the paper process

Labor not significantly different

There is a learning curve

The medication error rate is being evaluated


25

Another Place to Look!

Non-Service Recipient Care


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Non-Service Recipient Care (Continued)


27

A word about the Power of GROUPS orthe Wisdom of Crowds

(Workload Groups are also Enablers!)

People who do the work are the best people to find the needed improvements

Smart Groups Diverse Independent Decentralized Need a structured format Have Basic Ground Rules


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Using Simulation

Benefits Decrease up front investment Test new protocols and procedures before implementation Awareness of benefits and drawbacks before implementation

( surprises) Better awareness of cost benefit savings

Drawbacks In house expertise - if you have it If you don’t have in house expertise – long learning curve

Partnerships


29

Way Forward

Can “LEAN” utilizing workload data assist in achieving the goal initially stated?

Goal

Give to patients;Exactly what they need;

When they need it;Every time;Defect free;

In a safe environment;At the lowest cost;

Without waste.


30

Bibliography Barry, R., A. Murcko and C. Brubaker 2009. The Six sigma Book for Healthcare. Chicago, IL. Health Administration Press. Clancy, T. “Self-organization Versus Self-Management” Journal of Nursing Administration 39(3): 106-109.

Clancy, T. R. “Simulation Based Lean Six Sigma” (Presentation). GRASP® Systems Conference. Las Vegas, NV. 2008.

Fine, B. G., Hannam, R. & Morra, D. “Leading Lean: A Canadian Healthcare Leader’s Guide”, Healthcare Quarterly 12(3): 32 – 41. Hendrick, A., M.P. Chow and W.S. Goshert. 2009. “A Proclamation for Change: Transforming the Hospital Care Environment.” Journal of Nursing Administration 39(6): 266-275. Hendrick, A., M.P. Chow, B.A. Skierczynski and Z. Lu. 2008. “A 36-Hospital Time and Motion Study: How do Medical-Surgical Nurses Spend Their Time.” Permanente Journal 12(3): 2-9. Jimmerson, C. 2004, reView, Realizing Exceptional Value in Everyday Work. Bonner, MT: Lean Healthcare West.

Joint Commission on Accreditation of Healthcare Organizations. 2006. Doing More with Less: Lean Thinking and Patient Safety in Health Care. Ed. Porche, R. A. Oakbrook Terrace, IL. Liker, J. and D. Meier. 2006. Toyota Way Field Book. New York, NY: McGraw Hill.

May, M.E. 2007. The Elegant solution: Toyota’s Formula for Mastering Innovation. New York, NY: Free Press. Meadows, D. “Leverage Points: Places to Intervene in a System.” Available at http://www.sustainabilityinstitute.org/pubs/LeveragePoints.pdf. Accessed November 11, 2009.

O’Brien, Y., and P. Boat. 2009. “Getting Lean the Grassroots Way.” Nursing Management 40(9): 28-33. Ohno, Taiichi. 1988. Toyota Production System. New York, NY: Productivity Press. Spear, S.J. “Fixing Health Care from the Inside, Today.” Harvard Business Review 83(9): 78-91. Thompson, D.N., G.A. Wolf and S.J. Spear. 2003. “Driving Improvement in Patient Care: Lessons from Toyota.” Journal of Nursing Administration 33(11): 585-595.

http://www.sustainabilityinstitute.org/pubs/LeveragePoints.pdf

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Lean And Six-Sigma With Workload Data 1 Copyright © 2009 GRASP® Systems International Companies