improving the discharge process three hospitals’ perspective
TRANSCRIPT
Chuck DeBusk, GE Healthcare andKate Bombach, St. John Health
Improving the Discharge
Process:
Three Hospitals’
Perspective
Through a case study of the application of Lean Six Sigma to the discharge process in 3 hospitals at St. John Health show the following:
• How the application of the Lean Six Sigma process aids in improving the discharge process
• Similarities between three different hospitals
• Differences between the three hospitals
• Lessons learned from three applications
Objectives
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St. John Health System
•Member of Ascension Health. Largest not-for-profit Catholic Health Ministry in the United States, with acute care facilities in 15 states and the District of Colombia
•8 hospitals and over 100 medical facilities in Southeastern Michigan
•History in the Detroit area from 1844
•More than 10,000 babies are born at St. John hospitals each year
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Mission:
St John Health is committed to providing spiritually centered, holistic care which sustains and improves the health of individuals in the communities we serve, with special attention to the poor and vulnerable.
Vision:
To be the preferred healthcare provider in southeast Michigan by consistently providing the highest quality patient care experience in all that we do.
St. John Health System
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The Evolution of Lean Six Sigma at St. John Health•Launched Six Sigma Oct 31st, 2003 with GE
• 45 Projects (20 in sustained Control)• 2 MBB’s• 12 BB’s• 45 GB’s• 200+ YB’s• 240+ Change Agents
•Six Sigma Tool Kit includes: DMAIC, LEAN, Change Acceleration Process (CAP) and Work-Out
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Hospital Descriptions
St. John Hospital
• 560 Beds
• 31, 500 Discharges
• Top 100 Cardiovascular Hospitals
• Surgery
• Maternal/child Health Center
• Van Elslander Cancer Center
St. John Macomb
• 376 Beds
• 16,320 Discharges
• Surgery
• Cardiology
• Obstetrics (including special care
nursery)
• Rehabilitation
• Behavioral Health
St. John Providence
• 376 Beds
• 26,500 Discharges
• Aging Services
• Cardiac Care
• Oncology
• Orthopedics
• Pediatrics
• Women’s Health
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Initial Findings
St. John Hospital
• No process
• Physician orders inconsistent
• Family/ Transportation issues
• Patient information incorrect
St. John Macomb
• No process
• No urgency to processing
discharge orders
• Unclear roles
• Consults completed and
coordinated
St. John Providence
• No process• Discharge planning initiated day of discharge
• No urgency to discharging a patient
• Patient uninformed of the discharge
process
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Baseline Metrics
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100
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450
St. John Macomb Providence
Min
ute
s
Mean
Std. Dev.
USL
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Define
Analyze
Con
trol
Define Measure
Con
trol
EMERGENCY
SURGERY
DIRECT ADMITS
Define
Patient Admissions
Step 1 Step 2 Step 3 Step 4
DOCTOR
D/C order
Beds Assigned
Beds Available
D/C Order Read
Arrange Transport
Document &
Education
Patient
Leaves
Step 5
Bed Clean
Providence Hospital Six Sigma IP Throughput Projects
Step 6
Bed Available
Monitored Beds
Streamline IP Discharge and Bed Readiness
Reduce LOS by DRG
WAVE III Aligned (April – September 2005)IP Discharge (BB Kate Bombach) Decrease time from doc writes order to patient leaves room to 2 hours.
Throughput – Bed Clean (BB Michael Elias) Decrease time to clean bed by 44 minutes
Monitored Beds (BB Todd Sperl) Increase correct utilization of monitored beds
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Define Measure Analyze Control Improve
Who are the customers & what are their priorities?ED & Direct admit patients waiting for a bed.Voice of the Customer:“Discharge is a mess! Too many people doing the same things.”
How is the process performing & how is it measured?Mean = 289.1 minRange = 1487.0 minSt. Dev = 283.9 minZ-score = 1.40A defect is a discharge where the time btw. the written discharge order and patient left > 3 hours
What are the most important causes of defects? Over 40 wastes identified by the team. No standard communication, No clear roles, No monitoring or accountability.
How can we maintain the improvements?
How do we remove the causes of defects?
WorkOut 7/5/05•Patient Discharge Planning Flyer•Multidisciplinary Checklist•Discharge Section in patient chart with forms pre-stamped w/ patient id•Discharge Order Flag•Add Discharge Planning to Orders
PILOT Solutions 4W, ICCU and 3 AnnexMid-September
Providence Hospital Six Sigma Inpatient Discharge Project
April 2005 October 2005
Step 4
Patient Leaves
Step 2 Step 3
Notify Transport
Document &
Education
Step 1
Discharge Order Read
Step 0
Discharge Planning
Discharge Decision
We need LEAN!
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HUC/RN contacts MD if not completedHuc contacts ambulance for ECF transfer
MD
Writes order
Completes D/C order form
Writes Rx’s
Flags chart
TransportationIdentified as an issue at this point of discharge process
Inpatient Discharge - Map
Delays
RNRN or HUC picks up chart
HUC transcribes orders
RN notes order
RN communicates with patient
RN or HUC communicates with case manager
RN notifies family or Pt. Notifies family
RN completes appropriate d/c form
RN clarifies orders, transcribes on MD d/c order form if not done by MD, then transcribes on to RN d/c order forms also
Incomplete TestsLab tests – phone calls
Radiology – CT, X-ray
Cardiology- cardiac cath,
Consults ECFTransfer Forms completed by
Case Manager
Patient’s family arrives
Patient leaves
Chart
Transport – volunteer, PCT, RN, transporter
Order sitsHUC on duty?
RN identifies outstanding issues related to discharge
i.e incomplete consults
Discharge InstructionsPt.’s understanding
House MD
Wait for family
Equipment/ Home Care
Meds/ Placement issues discussed with case
manager
Legibility/clarification of incomplete forms
Rx’s needed
Pending Orders
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Md tells patient They are going
home
Writes complete D/c order
HUC notes orderDates and times
MD order
Notifies CM and RN of d/c
Via spectralink
Rn completes paperwork
Reviews pt. InstructionsAnd RX’s
Transportation picks Up pt.
HUC
RN
TRPT.
MD
CM
Returns chartTo d/c rack
If order written as pending Md consults, CM makes calls if
RN unavailable
If HUC not at desk thenRN notes order
If pt. Able to walkEscorted by staff
If MD forgets to place chartIn rack, any staff member
Can check chart and place in rack
Places chart inDischarge rack
Notifies transportationTo pick up pt.
If order written asD/c home with DME, charity
Meds,home care
CM completes all aspects of D/C
Future State Swim Lane Map Discharge Process
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Solutions
St. John Hospital
•Discharge Checklist
• Verify Registration information
• Probable Discharge Order
written 24 hours prior to discharge
• Patient Brochure
St. John Macomb
• Flow Diagram
• Designated Discharge Rack
• Spectralink phones used to notify RN and CM patient ready for d/c.
St. John Providence
• Patient Flyer
• Color Coding Patient Chart
• Flow Diagram
• Discharge Checklist
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0
50
100
150
200
250
300
350
400
450
St. John Macomb Providence
Min
ute
s
Mean
Std. Dev.
Post Project Metrics
USL
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Lessons Learned:
•Lean approach needed when there is no process, no standard communication, no clearly defined roles and responsibilities.
•Each of the hospitals had different causes for delays in the discharge process. Different expectations for staff. Different technology to manage beds.
•Solutions are accepted and adopted as “the way we do business”, only if change management tools are used.
•To translate the project to the other hospitals, standardization will be hardwired due to the eCare project.
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LEAN Road Map
No process exists. Process is out of control. Goal is to eliminate wastes FIRST. LEAN
Physical layout and/or materials get in the way of doing the work LEAN
Multi-step process and the goal is to shorten the total process time (process steps may be eliminated) LEAN
Complex processes are difficult to manage, communicate and train LEAN
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•Develop Value Stream Maps to identify potential LEAN and six sigma projects
•All LEAN projects will follow a 7-week process
•Hold LEAN teams accountable for measurements, targets, and use of Lean tools
•Standardize work through LEAN prior to a six sigma project
•Accountability built in with 7 day, 14 day and 21 day report outs
LEAN Road Map continued
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D.M.A.I.C
Follow Established Tollgate/Milestones
LEAN
Established: Tollgate/Milestones
D.M.A.I.C & LEAN
NEED: Tollgate/Milestones
Du
ration: 4 M
onth
s
Du
ration: 7 W
eeks
Du
ration: 4 M
onth
s
If Pr
oces
s is i
n Co
ntro
l & D
ata
Colle
ctio
n To
ol e
xist
s
If Pr
oces
s is o
ut of
Con
trol o
r
No Dat
a Coll
ectio
n Too
l or
SOP
exist
s
If a c
ombin
ation
of th
e abo
ve
exist
s or d
oesn
’t ex
ist
Project Scoping Phase. This phase will require clearly defined deliverables that will enable Black Belts to decide if the project will follow the DMAIC, LEAN or a combined path.
Scoping Phase Guidelines
Project Idea
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Questions ?
For questions regarding the presentation contact:
Chuck DeBusk,
Master Black Belt
763 561 9230
Kate Bombach,
Black Belt
248 849 3167
Special thanks to:
Sue Kozlowski, Black Belt, St. John Oakland Hospital
Surita Dexter, Black Belt, St. John Macomb Hospital