applying the lean methodology for improved patient flow
DESCRIPTION
Prof David Ben-Tovim, Director Redesigning Care, Flinders Medical Centre and Southern Adelaide Local Health Care Network delivered this presentation at the 6th annual Hospital Bed Management & Patient Flow conference 2013 in Melbourne. For more information on the annual event, please visit the conference website: http://bit.ly/1f3Pp03TRANSCRIPT
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
1
2
3
4
5
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
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
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
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
Diagnose Two major value streams Outliers, and Care Progression
Build authorisation
and permission
A3
Scope Division Medicine- arrival through to discharge
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
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
Diagnose Two major value streams Outliers, and Care Progression
A3
Scope Division Medicine- arrival through to discharge
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
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
Diagnose Two major value streams Outliers, and Care Progression
A3
Scope Division Medicine- arrival through to discharge
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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