Applying the Lean Methodology for Improved Patient Flow

Applying Lean Methodology for Improved Patient Flow

Prof. David I Ben-Tovim Redesigning Care

Flinders Medical Centre Southern Adelaide Local Health

Network

New wing St Thomas’s Hospital 1842

American Civil War Hospital

Withington Hosptial 1981

nv sier Nursing

Med

Managerial

The basic insight

Patients make horizontal journeys through

vertical organisations

Div surgery Div Med

Why Lean?

But Hospitals are organised vertically

Running

Board Commutators Front axle

Radiator Gas Tank Rear axle

Assembly Line

R

A

W

M

A

T

E

RI

A

L

S

Flow production - raw materials come in one end, get transformed step by step along a continuously moving production line until a

motor car comes out the other end

Flow production (Model T style)

Mass Production

> Flow production does not work when you need variety. So Ford moved to mass production.

> In mass production, production is organised by function in production villages.

> A production village is a group of people in a physical location, a cluster of buildings, machines, etc with only one specialised function

> And now you start to have the problem of co-ordination

Mass Production

Annealing Stamping Painting

Washing Welding Brazing

Assembly Line

Mass production

Spaghetti World

Assembly Components Piece Parts Process

Lean Thinking

• Is basically a whole set of strategies to improve

the scheduling and co-ordination of complicated

design and production processes

• And since it is the people who do the work that

are ‘up close and personal’ with the effects of

poor scheduling and co-ordination, it makes

sense to involve them at every step.

• Using a well-structured implementation

methodology

P D

A S

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2

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Diagnostic Phase

Scope Embed Sustain Improve

Assess Impact

Intervention Phase

P D

A S

P D

A S

P D

A S

P D

A S

Lean principles

Problem

Real Problem

• Specify value from the standpoint of your customer

• Identify the value stream for each product family

• Make the product flow and eliminate waste

• So the customer can pull

• As you manage toward perfection

The Problem.

Evidence of impact on primary

purpose

Problem or Concern?

Define Scope

First and last step in the process of interest.

Diagnose

Map

o Track

Look for value stream

Define Metrics-Patient,

Staff, Institutional views

The real problem

Analyse

Redesign

Possibility of counter measures to stabilise

situation-but balance short and long term

outcomes

First experiment ─PDSA

o Second Experiment─PDSA

etc

Identify work standards +/- standard work

Evaluate

Quantitative and qualitative measures

Embed and Sustain

Confirm work standards +/- standard work

New way is the way we do it round here

Gant chart- who, what, when, reports, timing, etc

Signed and dated………..

RGH; All (Elective+emergency)

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Actual OBD Expected OBD

Hospital crowded and over-budget, patients staying too long,

Evidence of impact Transfers from other hospitals refused because over-crowded-impact both within rgh and FMC

Scope

Buildauthorisation and

permission

A3



Diagnose

Build authorisation

and permission

A3

Scope Division Medicine- arrival through to discharge

Which

patient

groups do

we choose

to send to

RGH?

Who is

involved?

Is there a

standard

process for

preparation at

FMC?

Who is

involved?

How

much

work

up is

done?

Are they always

accepted?

What/How

transport

is used?

Handover

Pt’s from FMC

Early am

transfers

Four

Required

Gen Med Resp Card

Triage nse S/C night ED Med staff Med Reg Spec Reg DFC in am ED CSC in am AAU CSC

Nse Checklist Med Checklist

DFC Med Reg Spec Reg

Most No -Escalation ring night before -MRO capacity -DFC checks with RGH B/manager - Some refuse to go.

SAAS - DFC

How- nse Wriiten Medical : Mob phone When: 0800-0830 Who gives: Night Med reg GMA, Spec reg Spec RGH.

Pt’s from FMC

Day Transfers

Two Req (

total Six)

-Overnight Gen med adm -Short Long -5-9pm cohort

AAU CSC AAU consultant

Nse Checklist Med Checklist

CSC Primary Nse RMO

Most No - 0855: CSC checks with RGH B/manager -Escalation at 0855 -MRO capacity -Some refuse to go.

RGH transporter SAAS 2nd choice

How- nse Wriiten Medical : Mob phone When: 0900-1300 Who gives: AAU RMO GMA,

Rehab Stroke/Neuro Elect Ortho Funct decline Fract NOF

Rehab CPC team, Rhab Reg; Consultant

Post referral assessed < 24hrs, 3 outcomes -Accepted -For Review -Declined

Rehab CPC. Reg; Stroke Cons: CA

Most No Also Triage to other services -RITHOM, Day Rehab, REACT , GEM + other

SAAS, access cab, RGH transporter.

Assessment form by CPC/triage is the Handover. Casenotes come with pt. No Dr to Dr H/O

Other pt’s

from FMC

In hrs

Urology

Urol Med No N/A Some Yes SAAS - DFC -Ward Clerk

FMC Urol Med to RGH Urol med timely

No nursing letter.

Issues at this

stage?

Identifying enough suitable patients

Time consuming

If spec rad req will not be able to send

MRO an issue for all beds SAAS excellent



Diagnose Two major value streams Outliers, and Care Progression

Build authorisation

and permission

A3


Picturefield

Place images in their own

white space – image

does not have to be this

size or always sit here.

Plan

Repat 2: Redesign for the Patient.

What is the problem: Lack of visibility of clinical and non- clinical processes to understand

the timing of the patient journey.

Longer LOS against benchmark.

Patients are not exiting RGH in a timely manner, resulting in the hospital

census being 105% occupancy.

High % of outliers which is restricting access for other patients.

Unless processes are visible, the opportunities are unable to be

maximised to improve timeliness of patient Journey, reduce variation

and ensure effective deployment of resources.

Current State: RGH working at 105% occupancy over winter 2010

Routine transfers numbers …% below target

36 % of Acute beds are Blue Dots pt’s, many with barriers, Social work

struggling

Avg of 14 unfunded flex beds open during winter.

15% of all OBD’s are Maintenance Care ( comp with 6% for most other

hospitals)

LOS data- day of admission ALOS

Transferred patients Matched cohort LOS 36 hrs to 48 hrs longer than

FMC

Weekend D/C rate is 15% ( target is 29%)

Follow up/ Evaluation/Outcomes

Recommendations/Countermeasures

Aims: To maximise RGH resources to continue to deliver high quality and

timely patient care to the growing number of patient requiring access.

October 2010 •Big Picture Mapping

occurred on the 13th

October: 55 attendees, all

disciplines well represented.

•Four obvious area of

opportunities

•Oultiers: Discharge

Planning: Take

Roster:

Communication

Authors: Lauri O’Brien, Pamela Everingham. David Ben-Tovim Jan 2011

Next Steps •Governance structure: Steering Group Met 8th Dec 2010.

•Two Workgroups being established. Outlier Management &

Discharge Processes. Weekly meetings to commence mid Feb

2011.

•Training Day, 1st March. To include steering group, work groups and ward staff




A3


Ward Round redesign Journey Board introduced and used Allied health Unit based and major Wards restructured

Real Problem Major redesign required for allied health practices

Key: Needs / Referred Seen Unsuit for D/C F/U for D/C GTG

Alloc Nurse

Bed Patient Team Pre admit

profile

Health Referrals LOS EDD

Discharge Destination

Waiting For

PSY PT OT SW DN SP Other

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Repat 2: Redesign for Patients.

ALLIED HEALTH WORK GROUP PROGRESS REPORT

What is the problem: 4 Broad Issues facing Allied Health have been identified: 1/ How do we allocate ourselves to services (wards or units?) 2/ How do we manage our workload within existing staffing resources and provide cover for planned/unplanned leave? 3/How do we redesign our processes to meet changing demand 4/ How do we meet future demand? (how does allied health work in the medical ward reconfiguration)

Next Steps

- Repeat Self tracking

- Establish Hub Boards

- Establish staff identification process

- AHRO modification

- Identify next 3 improvement projects

Authors: Karen Brown, Steve Basso, Mel Lewis, Lauri O’Brien

1st Feb 2013

Issue Action

Need to identify AH structure and

function issues •Work group formed to manage ongoing

improvement strategies- meet monthly and report to AH leadership group.

Need to gather accurate data on current work practices- tracking

•Initial tracking late 2011. Re-tracking planned 14th February

Need to identify consumer satisfaction levels

• Survey results presented to Consumer council

Need to review current leave patterns, polices and practices

•Standard leave management guidelines accepted and adopted across all AH depts

Need to establish clear referral guidelines

• revised referral guidelines distributed

•Oacis use guidelines completed & distributed

Need to establish clear assessment priority guidelines

• amended guidelines distributed

Time and efficiency of clinical handover processes

Need to identify AH best fit with ward/ medical team reconfiguration process

26% reduction in clinical handovers

achieved

Workgroup established to manage 3 initial improvements from list of 40+ identified by AH staff survey

Interventions Progress

Allied Health staff working

in acute wards all unit

based.

Communication and

function issues post

reconfiguration reviewed.

Staff identification and

client contact processes

Fully implemented

Survey about options for clearer staff

identification (from staff and patient

surveys)

Hub Board designed and to be installed

in wards in late February.

Leave cover processes Completed

Clinical handovers

Reduced internal handovers but to

modify handover formats and processes

in line with hospital clinical handover

committee

Referrals & referral

guidelines

Completed

Allied Health Referral

Officer role review

Tracking completed, staff survey

completed, decision to modify role into

AH team leader with more relevant

functions




A3


Ward Round redesign Journey Board introduced and used Allied health Unit based and major Wards restructured

Real Problem Major redesign required for allied health practices

Program extended to Urology

Plans:

• Theatre schedules & Emergency theatre review & analysis

- possible Urology surgery 5 days/week- possible ‘emergency’ theatre list-

Re-scheduled some Urology lists to give better cover across week.

• Review registrar roles to ‘even up’ work load- Developed new

guidelines, to be micro managed and formally reported on fortnightly

• Review surgical booking format/ processes- Developed initial

electronic format for trial from February

• Review current orientation and information formats and processes for

patients and staff- new information/ orientation packages developed

and implemented from February

Repat 2: Redesign for the Patient.

Surgical Services Urology Workgroup Progress Report

What is the problem: Surgical Booking policies and practices leading to delays,

inefficiencies, problems with bed management and patient

complaints

Follow up/ Evaluation: • Assess outcomes from PAC interventions

• Monthly updates to BPM session attendees about findings, actions and

outcomes

• Future Directions session March 2013.

Authors: Steve Basso, Lauri O’Brien, Viv Ma Feb 1st 2013

Issue Intervention & Outcomes Progress

1.1 delays and perceived inefficiencies in

some surgical service provisions- Urology

Leadership group- fortnightly meeting

1.2 uncertain about extent of or specific

nature of current perceived problems- Urology

Big Picture Mapping process 27th July- 40

attendees and 3 facilitators.- number of issues

agreed about.

1.3 need to gather appropriate data to help

identify current state and inform issues

identification

Significant data gathering, tracking RMO/registrars,

target based capacity and demand

Theatre utilisation data collated.

1.4 develop work groups for issues identified

at Big Picture Mapping and from Leadership

group

Work group established- fortnightly work group

meetings

1.5 apparent capacity and demand mismatch Epidemiology unit at FMC analysed comprehensive

target-based demand and activity data

1.6 workload for medical staff Tracking ‘junior’ medical officers Aug 7trh and

Registrars Oct 15th. Business cases for increased

staffing.

1.7 medical consent and patient information

inconsistencies

Aligned with standard state systems and processes

1.8 Pre anaesthetic clinic function Review of current structure and functions- see next

section

Current State Diagnostic phase with ongoing reviews and assessments.

Some Interventions already developed and introduced

Pre Anaesthetic Clinic (PAC) and related processes:

Work group Diagnostics & Interventions

• Urine/blood test recording/reviewing- developed short term process in Ward

8 RMO room. Developed electronic options to trial in Feb

• Number of PAC visits- reducing from 2 to 1 visit. Working more efficiently

• Surgery delays on day of surgery- increased number of patients admitted at

start of session. Improved theatre session cancellations. Develop antibiotic

scheduling guidelines for RMO. Trial guidelines being completed

• Day of surgery patient information- draft information developed. Trial draft in

PAC

• PAC function and staff role information- developed draft of guidelines for all

PAC staff. Trail draft

• Aboriginal & Torres Strait islanders – establish formal, automated referrals/

communication with Karpa Ngarratendi- draft automated notifications

processes being developed- for application in all surgical units

• Alternatives to in hospital admissions pre surgery- identify strategies for

avoiding prolonged in patient stays for pre-surgery work-ups. Incorporate into

booking & PAC processes

Outcomes

Process Outcomes

• Improved structure and format of ward rounds

• Formal discharge planning meeting structure

• Better use Journey Boards

• Easy identification of Team Leaders at unit level

• Three-times weekly outlier discussions between unit CSC

• etc

Outcomes

Patient/Unit level outcomes 14% improvement in Relative [Length] of Stay Index –from 1.07 (ie well above national values) to 0.92 (well below) 46% decrease outliers 32% decrease in bed-use by Long-stay outliers ( 12 bed capacity increase) 15% increase medical separations, and 92% decrease in ‘escalation”= refusal to accept transfers/admissions because full.

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Health & Medicine

Applying the Lean Methodology for Improved Patient Flow