Presenters:Dale Strong, BS, E.I.T. – Information and Analytics Services, Clinical Analyst
Jeremy Rhoten, RN, BSN – Carolinas Medical Center, Stroke Program Coordinator
Sunday Learning Lab 11
Sunday, December 9, 201813:00
Improve Lives and Lower
Cost, Using Our Lean PI
Tools
DISCLOSURES
• Jeremy Rhoten, RN, BSN and Dale Strong, BS, E.I.T.
• Research -Penumbra Inc,
Jeremy Rhoten and Dale Strong today have no other relevant financial or
nonfinancial relationship(s) within the services described, reviewed, evaluated, or
compared in this presentation.
OBJECTIVES
• Recognize different process improvement methodologies and
gain confidence to implement them in any workplace
• Utilize different tools to identify sources of waste and develop
efficient solutions for improvement
• Discover feedback processes to help involve key stakeholders
in the success of a project
• Develop key strategies on how to ensure sustained success for
a complex workflow
• Discuss different ways to highlight successes so others can also
implement best practices
DISCLOSURES
• Jeremy Rhoten, RN, BSN
• Research
• Penumbra Inc.
• Dale Strong, BS, E.I.T
• Research
• Penumbra Inc.
AGENDA
• Introductions and backgrounds
• Overview of our experience with process improvement
• Introduction to process improvement methodologies
• Deep dive into the DMAIC process
• Case studies and review
• Group discussion and questions
BACKGROUND
• Jeremy Rhoten, RN, BSN, SCRN
• Currently working as the Comprehensive
Stroke Program Coordinator for Atrium
Health's flagship hospital, Carolinas Medical
Center.
• Graduated from Marshall University with an
ASN, University of Texas – Arlington with
and BSN.
• Early career included working as a Critical
Care nurse in Athens GA, Falls Church VA,
Phoenixville PA, and Charlotte NC.
• Worked extensively with process
improvement projects, data analytics, and
data visualization throughout career
BACKGROUND• Dale Strong, BS, E.I.T.
• Currently working as a Clinical Analyst for the Comprehensive Stroke Program at Atrium Health's flagship hospital, Carolinas Medical Center.
• Graduated from Clemson University with a Bachelor’s Degree in Bioengineering
• Early career included working for Stryker Endoscopy providing OR support, and as a Data Management Consultant
• Worked extensively with process improvement projects, data analytics, and data visualization throughout career
• Holds an Engineer In Training certificate, and has taken multiple courses in Lean and Six Sigma
PROCESS IMPROVEMENT
Results:
• Higher product quality
• Better customer satisfaction
• Increased productivity
• Development of employee skills
• Efficiency
• Potential higher and quicker return on investment
Definition: The proactive task of identifying, analyzing
and improving on existing business processes
PROCESS IMPROVEMENT
METHODOLOGIES
Lean
• More value for the
customer utilizing fewer
resources
• Process production that
strives for results in
perfect value with zero
waste
Six Sigma
• Set of tools and
techniques that improve
output quality by
removing defects and
minimizing variability
• Process measured by
Sigma Level
Total Quality Management
• Organizational effort to
establish a culture of
continuous
improvement
• No set definition, but
uses a wide variety of
quality control tools
PROCESS IMPROVEMENT
METHODOLOGIES
• PDSA: Plan, Do, Study, Act
• DMAIC: Define, Measure, Analyze, Implement, Control
OUR EXPERIENCE
• At Carolinas Medical Center, we were tasked with streamlining the
Code Stroke Process to expedite patient treatment in the acute
stroke setting
• 2 month long process following the DMAIC method
Define
• Brainstorming with all stakeholders involved
• Discussed with administration the ultimate goal for the workflow
Measure
• Analyzed available data and process metrics
• Observed the workflow in real-time
• Mapped out the current state process
Analyze
• 5 whys root cause analysis
• Looked for any sources of waste
• Developed new streamlined workflow
Improve
• Trialed different aspects of the new workflow
• Altered workflow based on feedback
• Reevaluated the new workflow to identify other sources of waste/inefficiencies
Control
• Finalized workflow, reevaluated data and process metrics to illustrate observed change
• Established continuous feedback loops with the clinical team to allow for further improvements
STROKE FACTS
• Classifications: Ischemic Stroke, Hemorrhagic Stroke,
Transient Ischemic Attack
• Stroke is the 5th leading cause of death in the U.S.
• Stroke is the leading cause of disability in the U.S.
• Close to 800,000 strokes occur in the U.S. every year
• Ischemic Stroke accounts for almost 87% of all cases
*All statistics from American Stroke Association Website
CODE STROKE
WORKFLOW
Steps
• Patient Arrival
• Recognition of Symptoms
• Radiological Imaging
• Treatment Decision
Time Is Brain!
Door to ED Physician
10 mins
Door to Code Stroke
15 mins
Door to CT Performed
25 mins
Door to CTA Performed
45 mins
Door to IVtPA
60 mins
45 mins (Stretch)
Door to Groin Puncture
90 mins
60 mins (Stretch)
NEEDS FINDING
Finding the right problem to solve is just as important as finding the solution
CODE STROKE PROCESS
IMPROVEMENT• American Stroke Association has established time goals for
acute stroke
1. Door to IVtPA: 60 minutes
2. Door to Groin Puncture: 90 minutes
Improvements Observed
(Change Between Pre and Post Data)
Door to ED
Physician
Door to Code
Stroke Activation
Door to CT
Performed
Door to CTA
Performed
Door to IV
tPA Bolus
Door to
Puncture
Door to Final
Revascularization
Average
1.3 6.2 3.9 8.9 9.7 20.8 23.7
Median
1.0 5.0 5.0 9.5 10.5 29.0 23.5
PROCESS IMPROVEMENT
IMPACT
• Door to IVtPA Bolus improved by 9.7 mins
• Door to Final Revasc. improved by 23.7 mins
• Patient population observed a decrease Length of Stay on
average of 2,603 mins (approx. 1.8 days)
• NIHSS at discharge improved 1.94 points
• mRS at discharge improved by 0.50 points
DMAIC INTRODUCTION
• Data driven strategy to improve
• More commonly associated with
Six Sigma
• 5 interconnected phases
• Cyclical process that can be
repeated for continuous
improvement
DEFINE
First Phase
Goal: Clearly articulate a problem and establish
a goal to improve on the highlighted problem
• Important to capture the customer input
Phase Tool Box:
• Project Charter
• SIPOC
• Value Stream Map
• Swimlane Map
• VOC
• A3
DEFINE TOOLBOX
• Project Charter
• Outline for the project
• Identifies core team,
stakeholders, and their
roles/responsibilities
• Clearly lists objectives for
the project
• Serves as a reference for
authority throughout the
project
https://expertprogrammanagement.com
DEFINE TOOLBOX
• A3
• Structured and strict guidelines for problem solving
• Fits on a single sheet of ISO-A3 size paper
• Helps illustrate the thinking behind the project
• Brings all project aspects together to keep stakeholders informed
DEFINE TOOLBOX
• SIPOC
• Suppliers, Inputs, Process, Outputs, Customers
• Visualize process from beginning (Suppliers) to end (Customers)
• Higher overview level and not much granular detail
Suppliers
• Who supplies the inputs?
Inputs
• What inputs are needed for the process?
Process
• What happens to the inputs to get your output?
Outputs
• What is the result of your process?
Customers
• Who benefits from or uses your outputs?
SIPOC - GoLeanSixSigma.com
DEFINE TOOLBOX
• VOC
• Voice of customer
• Translate what the customer is saying or describing into something tangible that you can measure and impact within your process
• Helps to maintain the progress focus around what’s most important… the customer
• Results in CTQs (Critical to Quality Requirements)
VOC
Large Customer Database
Surveys
Social Media Feedback
Purchase History
Direct Phone calls &
Interviews
Market Research
CODE STROKE
WORKFLOW TREND
Project Implementation
EMS CODE STROKE
PI PROJECT - DEFINE• Project Selection:
• Patients arrive via EMS, Private Vehicle, or Inter-Facility Transfer
• “Ranked” each arrival mode to determine which patient population/workflow to focus on for the PI Project
Project Volume Feasibility Potential Impact CMC Ownership Total (Multiply all)
EMS Arrival 3 3 2 3 54
Private Vehicle
Arrival2 2 3 3 36
Transfer Arrival 2 2 3 1 12
MEASURE
Second Phase
Goal: Understand how the process
performs in its current state
• Important to plan how to collect data,
ensure data reliability, and collect
baseline data
Phase Tool Box:
• Data collection plan
• Operational definitions
• Process maps
• Project charter
MEASURE TOOLBOX
• Process Map
• Diagram of the overall workflow
• Identifies necessary steps and parallel processes
• Multiple maps or flowcharts with slight differences depending on what you want to review
MEASURE TOOLBOX –
PROCESS FLOWCHART
MEASURE TOOLBOX –
PROCESS FLOWCHART
MEASURE TOOLBOX –
SWIMLANE DIAGRAM
MEASURE TOOLBOX
• Data Collection Plan
• Determine how you are going to gather data throughout the project
• What you collect?
• Who will collect?
• When will they collect?
• Sample of collection?
• Can be high level overview or go into detail as much as you want to
Data Collection Plan
Performance Measure
• CTQ
• VOC
Definition within the
project
Data Source
How will it be
collectedWho When
Sample Size
https://www.managementstudyguide.com/data-collection-plan.htm
ASSESSMENT OF CODE
STROKE WORKFLOW
Accuracy: Ability to hit your target and/or goal
Precision: Ability to consistently hit the same spot
(Pre-Project Implementation)
EMS CODE STROKE PI
PROJECT - MEASURE
Door to ED
Physician
Door to Code
Stroke
Activation
Door to CT
Performed
Door to CTA
Performed
Door to
IV tPA
Bolus
Door to
Puncture
Door to Final
Revascularization
Average8.1 20.3 29.6 46.3 59.1 111.3 137.0
Median4.0 12.0 22.0 36.0 52.0 108.0 134.5
Pre-Implementation Data
*All values in minutes
Door to ED Physician
10 mins
Door to Code Stroke
15 mins
Door to CT Performed
25 mins
Door to CTA Performed
45 mins
Door to IVtPA
60 mins
45 mins (Stretch)
Door to Groin Puncture
90 mins
60 mins (Stretch)
ANALYZEThird Phase
Goal: Identify the cause of the observed
problem
• Important to examine the process from all
angles, graphically display what you find,
identify causes of the problem and then
verify the causes
Phase Tool Box:
• Value Stream Map
• Value added flow analysis
• Pareto charts
• 5 Whys
ANALYZE TOOLBOX
• Root Cause Analysis
• Start with a visible issue and
then dive deeper to figure
cause of the problem
• Proactively eliminate issues
instead of waiting for them to
arise
1. What happened?
2. How did it happen?
3. Why did it happen?
4. What can I do to prevent it from
happening again?
5 Whys Technique
Fishbone Diagram
https://4improvement.one/knowledge/tools-techniques
https://leanmanufacturing.online/the-fishbone-diagram/
EMS CODE STROKE PI
PROJECT - ANALYZE• In 2017, CMC had 467 Code Stroke (CS) Patients present through the ED
• 333 via EMS = 71.3% of total ED CS Volume
• 134 via Private Vehicle = 28.7% of total ED CS Volume
• For Large Vessel Occlusion Strokes 1.9 million neurons die every minute a patient goes without treatment
• Average Door to Bolus Time for IVtPA 2017 (Jan-Jun) = 59.1 min [Goal = 60 min]
• Average Door to Groin Puncture for IA 2017 (Jan-Jun) = 111.3 min [Goal = 90 min]
5 Whys?
Technique
Why? Why? ROOT CAUSE
EMS CODE STROKE PI
PROJECT - ANALYZE
DOWNTIME = 8 Sources of Waste
D
Defects
O
Overproduction
W
Waiting
N
Not-Utilized Talent
T
Transportation
I
Inventory
M
Motion
E
Extra Processing
EMS CODE STROKE PI
PROJECT - ANALYZE
• DOWNTIME: 8 Sources of Waste
• Extra Processing: 3 different personnel view patient before CS
Activation Page
• Transportation: moving patient between ED and Radiology
multiple times
• Waiting: depending on treatment strategy the patient was spending
excess time waiting for decisions/supplies
• Motion: clinical decision makers are also tasked with moving
patient multiple times while making the best decision for the
patient caused excess motion in the process
IMPROVE
Fourth Phase
Goal: Implement and check your
solution
• Important to brainstorm, choose realistic
solutions, illustrate the solution, create a
plan that includes multiple solutions when
possible
Phase Tool Box:
• Brainstorming
• PICK diagram
• PDSA/PDCA
• Implementation plan
Brainstorming
Stepladder Technique
Word Association
Writing Down
Individual Ideas
Figure Storming
Rapid-Fire
Round Robin Style
IMPROVE TOOLBOX
• Brainstorming
• Any tool that involves
getting the project group
generating thoughts and
discussions around the
process
• Important start to critical
thinking
• There are many ways to
brainstorm, and the right tool
depends on the project.
IMPROVE TOOLBOX
• PICK Diagram
• A tool to determine which option has the greatest value or impact
• Ranks ideas according to elements that are important to your project team
• Helps eliminate bias in idea selection
Project Volume Feasibility Potential Impact CMC Ownership Total (Multiply all)
EMS Arrival 3 3 2 3 54
Private Vehicle
Arrival2 2 3 3 36
Transfer Arrival 2 2 3 1 12
IMPROVE TOOLBOX• Project Implementation Plan
• Takes strategies discussed and turns them into actionable items
• Puts all team members on the same page and assigns responsibilities
• There are many ways to do this so developing a way that works for your
team is what’s most important
CSC Mock Survey Planning OrganizerSelect a period to highlight at right. A legend describing the charting follows. Plan Duration Actual Start % Complete Actual (beyond plan)
ACTIVITY PLAN START PLAN DURATION ACTUAL STARTACTUAL
DURATIONPERCENT COMPLETE Weeks
1 2 3 4 5 6 7 8 9 10
Book Rooms 1 1 1 1 100%
Finalize Opening Presentation 1 5 1 5 100%
Print Opening Presentation 6 5 6 5 100%
Schedule ED Session 1 5 1 5 100%
Finalize System Tracer 1 5 1 5 99%
Book System Tracer 1 5 1 5 100%
Print System Tracer 6 5 6 5 99%
Schedule Credentialing 1 5 1 5 100%
Print Patient List 1 5 1 5 100%
Order Set 1 5 1 5 100%
Approval On-Call Schedule for Last 3 Months 1 5 1 5 100%
Print On-Call Schedule for Last 3 Months 6 5 6 5 100%
Patient Education 1 5 1 5 100%
Print InHouse Code Stroke Process 6 5 6 5 100%
Print ED Code Stroke Process 6 5 6 5 100%
Public Reporting of Outcomes 1 10
Core Team 6 5 6 5 100%
Obtain Transfer/DC Policies 1 5
Print Transfer/DC 6 5
Follow Up Call: Confirm Documentation 6 5 6 5 100%
Finalize Program Plan 1 5 1 5 100%
Print Program Plan 6 5 6 5 100%
Obtain Thermoregulation Protocol 1 5 1 5 100%
Print Thermoregulation Protocol 6 5 6 5 100%
Obtain Diagnostic Catheter Angio Report 1 5 1 5 100%
Add Diagnostic Catheter Angio Report to System Tracer 6 5 6 5 100%
Update PDSAs 1 5 1 5 99%
Print PDSA's 6 5 6 5 99%
Print Education Plan 6 5 6 5 100%
EMS CODE STROKE PI
PROJECT - IMPROVE
• Innovative new workflow that placed
patient at the center of attention
• Core Value Stream flows through
patient not the clinical team
• Patient may never enter the ED helping
reduce arrival time to treatment
• Full implementation took approx. 1
month beginning June 5, 2017 and
ending July 17, 2017
EMS CODE STROKE PI
PROJECT - IMPROVE
Post-Implementation Data Analysis
Improvements Observed (Change Between Pre and Post)
Door to ED
Physician
Door to Code
Stroke Activation
Door to CT
Performed
Door to CTA
Performed
Door to IV
tPA Bolus
Door to
Puncture
Door to Final
Revascularization
Average6.8 14.1 25.6 37.4 49.4 90.5 113.3
Median3.0 7.0 17.0 26.5 41.5 79.0 111.0
Door to ED
Physician
Door to Code
Stroke Activation
Door to CT
Performed
Door to CTA
Performed
Door to IV
tPA Bolus
Door to
Puncture
Door to Final
Revascularization
Average
1.3 6.2 3.9 8.9 9.7 20.8 23.7
Median
1.0 5.0 5.0 9.5 10.5 29.0 23.5
*All values in minutes
CONTROL
Last Phase
Goal: Maintain your solution
• Important to document the process,
apply what you learned to other
areas, ensure management is aware
of the new solution, and
share/celebrate your work
Phase Tool Box:
• Control plan
• Control chart
CONTROL TOOLBOX
• Control Plan
• Describes what must happen at each step of the process to ensure a
quality output
• Holds the group accountable to ensure the success of the new process
• Can include a multitude of information that is generated throughout
the project
Process Flowchart
Process FMEA Control Plan
CONTROL TOOLBOX
• FMEA: Failure Mode Effect Analysis
• Analysis of your product or process finding failure modes,
measuring their effect, and mitigating risk
• By identifying the largest risks for failure you can systematically
focus your control plan
• Most analysis rank failure modes by level of severity, frequency, and
detectability
Process Step/Input Failure Mode Failure Effect Sev
erit
y
Causes Freq
uen
cy
Current State Control Det
ect
ion
Ris
k P
rio
rit
y N
um
ber
(R
PN
)
Corrective Action Responsibility Actions Sev
erit
y
Freq
uen
cy
Det
ect
ion
Ris
k P
rio
rit
y N
um
ber
(R
PN
)
1
2
3
4
5
https://goleansixsigma.com/failure-modes-effects-analysis-fmea/
EMS CODE STROKE PI
PROJECT – CONTROL/RESULTS• Door to IVtPA Bolus improved by 9.7 mins
• Door to Final Revasc. Improved by 23.7 mins
• Average savings of 45.03 million neurons per patient with LVO
• Average savings of 73.47 weeks of life expectancy per patient with LVO
• Patient population observed a decrease Length of Stay on average of 2,603 mins
(approx. 1.8 days) saving an estimated cost of $1,940 per patient
• NIHSS at discharge improved 1.94 points
• mRS at discharge improved by 0.50 points
• Mean lifetime cost of an ischemic stroke was $140,048 (est. in 2010)
• Improved function prior to discharge can drastically impact overall cost
WHY WE DID IT
• Stroke is the 5th leading cause of death in the U.S.
• Stroke is the leading cause of disability in the U.S.
• Close to 800,000 strokes occur in the U.S. every year
• Finding the right problem to solve for this population allowed
us to have the greatest impact for this important clinical
population
*All statistics from American Stroke Association Website
REVIEW
• Lean Methodology Goal : process that results in perfect value
that has zero waste
• Six Sigma Methodology Goal : improving output quality by
removing defects and minimizing variability
• PDSA/PDCA and DMAIC are two major ways to organize a
project with different steps for each part of the project
• There exists a large toolbox for process improvement projects
that can help organize a team around a central goal that
produces results
CONCLUSION• Process Improvement can be a powerful tool in any business
setting
• There’s a large array of different tools that can be applied to a
variety of different projects
• When used properly there can be a profound impact on a process
or product
• While expertise and experience can be beneficial, anyone can
make an impact through process improvement
QUESTIONS?