changing patient and workflow paradigms at hospital de la concepciÓn emergency ... · nurses sup....
TRANSCRIPT
CHANGING PATIENT AND WORKFLOW PARADIGMS AT HOSPITAL DE LA CONCEPCIÓN EMERGENCY DEPARTMENT
Society for Healthcare Systems SHS 2006
Noris Torres Santiago, MSIE, PEHealth Systems Engineering DivisionCIRACET Corp
Hospital De La Concepción
l 167 Licensed beds
l 750 admissions per month
Emergency Department
l Fast Track and Observation Area
l 3,105 ED visits per month
l 80% of the ED visits go through the “Fast Track Service”
l 70% of the hospital admissions originate at the ED
l 20% of the ED visits are admitted
The problem:The effect
Reduction ofPersonnel Satisfaction
Unsatisfactorytime from arrival
to MD Eval
UnsatisfactoryLOS
Reduction ofPatient
Satisfaction
The approach:Lean Six Sigma
Lean Six Sigma
DelightCustomers
ImproveProcesses
Qua
lity
Spe
ed
Var
iati
on&
Def
ects
Pro
cess
Flo
wData and Facts
TeamWork
Reference: What is Lean Six Sigma? By: M. George, D. Rowlands, and B. Kastle
Voice of the Customer toCritical to Quality (CTQs)
l What are the customers needs andexpectations?
l Arrival to MD Evaluation = 40 minl LOS = 4.0 hours
Value Stream Mapping
Flow Chart of ED Process
Actual Layout
STAI
R-1
VENDING MACHINE AREA
TOILET TOILET
FAST TRACK
STAFF LOUNGE ADMITING AREA
NURSES SUP.MALES
STAFF LOCK
BATH RM BATH RM
PROCESSING AREA
EMERGENCY DEPARTMENT
SERVICESCUSTOMER
RMBEREAVEMENT
MEDICAL DIRECTOR
SEC.
CODE RM X -RAY
CA1
CA2
OBGYNTRAUMA ROOM
STATIONNURSE
MEDPREP
CONSULTING
PARKEQUIP
O2
ISOLATION
OFFICE
TOILET
TOILET
CA3
O1 ISOLATION
FEMALES STAFF LOCK
Triage
Financial Record
Nurses
Exam Room 1&2
IV and Respiratory Treatment Room
Exam Room 3&4
Waiting Room
Patient Flow Paradigms
l Fast Track is only a name
l Fast Track is Medical Evaluation
l Patient goes to the waiting room after eachstep in the process.
Patient Flow Paradigms
l 2 MDs at the “Fast Track Area” evaluates 87.2% of the ED visits.
l 1 MD at the Observation Area only evaluates 12.8% of the ED visits.
l Serial Processes
l Patient can not be seen by the doctor if Financial Registration is not completed (unless is an emergency).
EFFECT: UNBALANCED WORKLOAD
Patient Flow Paradigms
l IV and Respiratory Therapy Room (Fast Track Treatment Room) is far away from the nurses station.
Let’s measure
Average Visits per shift
39.537.3
12.5
0
5
10
15
20
25
30
35
40
Shift
7 to 3
3 to 11
11 to 7
Average Visits by day of the week
75
80
85
90
95
100
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Valley
PeakPeak
Average visits per hour
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
12 A
M1
AM
2 A
M3
AM4
AM
5 A
M6
AM7
AM8
AM
9 A
M
10 A
M
11 A
M12
PM
1 PM
2 PM
3 PM
4 PM
5 PM
6 PM
7 PM
8 PM
9 PM
10 P
M
11 P
M
Hour
Pat
ien
ts p
er H
our Peaks
Valley
Laboratories and X-Rays
l Laboratories are performed to more than85% of the patients.
l X-Rays are performed to 20% of the patients.
Measure
Six Sigma
Let’s measure variability!
Process Capability
l Provides management with a single number to assess the performance of a process or its improvement over time.
l Cp, P, Cpk
l Process Sigma
Process Sigma
LSL USL
The area under the curve between the LSL and USL is expressed as the yield.
Process Sigma Calculation
15.9%841,3450.5
30.9%691,4621
42.1%579,2601.3
46.0%539,8281.4
69.1%308,5382
93.3%66,8073
99.38%6,2104
99.977%2335
99.99966%3.46
YieldDPMOSigma
Arrival to MD
Business Goal = 0.5 hrs
The processTime from Arrival to MD Evaluation
Average = 1.24 Average = 1.24 hrshrsSD = 0.67SD = 0.67N = 411N = 411
TriageFinancialRecord
Physician Evaluation
Control Chart for Time from Arrival to MD
Observation
Ind
ivid
ua
l V
alu
e
41137032928824720616512483421
3.0
2.5
2.0
1.5
1.0
0.5
0.0
-0.5
_X=1.236
UCL=2.882
LCL=-0.409
111
I Chart of Arrival to MD
Process Capability Analysis for the Time from Arrival to MD Evaluation
1.60.80.0-0.8-1.6-2.4
LSL* USL*
transformed dataProcess Data
Sample N 411
StDev 0.665895Shape1 2.37362
Shape2 1.69675
Location -0.284501
LSL
Scale 7.19549
A fter Transformation
LSL* -3.03922Target* *
USL* -1.19077
Sample Mean*
0
-0.0212643
StDev * 0.994753
Target *
USL 0.5
Sample Mean 1.2363
O v erall C apabilityPp 0.31
PPL 1.01
PPU -0.39
Ppk -0.39
O bserv ed PerformancePPM < LSL 0
PPM > USL 875912
PPM Total 875912
Exp. O v erall PerformancePPM < LSL 1207
PPM > USL 880137
PPM Total 881345
Process Capability of Arrival to MDJohnson Transformation with SB Distribution Type2.374 + 1.697 * Log( ( X + 0.285 ) / ( 6.911 - X ) )
Length of Stay
Transfers to another institution, ER to OR, ER to OBGyn, and LAMA were not considered.
Business Goal = 3.0 hrs
The processLength of Stay
Average = 4.93 Average = 4.93 hrshrsSD = 2.92SD = 2.92N = 469N = 469
TriageFinancialRecord
Physician Evaluation
Treatment Discharge
Process Sigma Analysis for Fast Track Area LOS
In
div
idu
al V
alu
e
19117215313411596775839201
10
5
0
_X=4.22
UCL=9.63
LCL=-1.19
Mo
vin
g R
an
ge
19117215313411596775839201
8
4
0
__MR=2.035
UCL=6.647
LCL=0
Observation
Va
lue
s
190185180175170
10
5
0
9.07.56.04.53.01.50.0
LSL USL
Specifications
LSL 0.5
USL 4.0
12840
Within
O v erall
Specs
Within
StDev 1.80368
C p 0.32
C pk -0.04
O v erall
StDev 2.02305
Pp 0.29
Ppk -0.04
C pm *
11
11
1
1
Process Capability Sixpack of FT LOS
I Chart
Moving Range Chart
Last 25 Observations
Capability Histogram
Normal Prob PlotA D: 0.858, P: 0.027
Capability Plot
Process Sigma Calculation for Fast Track Area LOS
1.46SigmaProcess =
Measure
Lean
Let’s measure how fast is the process!
Value Stream Mapping
Capacity Analysis for the Fast Track Area (For 7 to 3 and 3 to 11 shifts)
3.3 (5.0)7.515.08.1Patients per hour
14.7 (9.8)5.23.06.0Cycle Time
2 (3)221Resources
26.5 (39.8)6012065Patients per shift
29.410.56.06.0Process Time
NurseMDFRTriage(Time in min)
Average Demand: 39 patientsMaximum Demand: 59 patients
You are only as strong as your constraint
Treatment: Nurses
3.3 patients per hour26.5 patients per shift
Process Cycle Efficiency (PCE)
l PCE is an expression of the portion of value added work within the cycle time.
l Average PCE = 10%
l Lean Goal = 25%
14.08.295
89.42===
åtimetotal
timesservicePCE
Patients Left Prior to each step of the process at the Fast Track Area
2Re-Evaluation
16At the Observation Area
3On-Treatment
(waiting for results)
6Treatment
2Physician Evaluation
2Financial Record
1Triage
QuantityPatients left prior to
Analyze
Wastes in the system
l Waiting time
l Transportation
l Processing
l Motion
l Defects
Changes
l A New Layout and Pneumatic system for the Fast Track Area.
l Change the workflow.
l Clerk for the Fast Track Area.
l Bedside Registration.
l Triage classification and processes
Triage MD Eval.
Changes
l Laboratoryl One Phlebotomist was hired for the 3 to 11 shift
l X-Rayl X-Ray Room at the ER
l Admissions Departmentl Coordinator at the ED
l More communication
Pick Chart
Implement Possible
Challenge Kill
• Work Balance• Disposition placed by RN• More lab resources• Admission coordinator
in ED
• HIS access to the host• Bedside registration
• Layout• Relocate pneumatic tube
BIG Payoff SMALL Payoff
EASYto implement
HARDto implement
DATA
ENTRY
ELECTRICAL KM
STO.
EKG.EXAM. KM
STAI
R-1
VENDING MACHINE AREA
TOILET
NURSES SUP.
TOILET
TOILET
StretchersAnd
Wheelchairs
OFFICE
Triage Exam Room
1
Exam Room
2
Exam Room
3
Exam Room
4
Fin Reg
Fast Track
Layout Alternative 1
Proposed Work Flow
Results
4.94.6
4.2 4.13.9 3.9
3.0
1.2 1.2 1.2 1.1 1.00.8
0.5
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
July August October GOAL
Questions and Answers
CIRACET CorpPO Box 8970Ponce, PR 00732
www.ciracet.com
Thanks to SHS and Thanks to SHS and to the audience!to the audience!