APPLYING LEAN PRINCIPLES TO A CONTINUING CARE PATIENT DISCHARGE PROCESS

Valerie Maier-Speredelozzi, Amy Thompson, Paul Hossfield, Stephen Abby Department of Industrial and Manufacturing Engineering, University of Rhode Island Gilbreth Hall, 2 East Alumni Avenue, Kingston, RI 02881, USA Abstract
Principles and tools that were developed for lean manufacturing can potentially improve efficiency and competitiveness across a wide range of industries, including healthcare. In this project, lean principles were applied to the discharge process at a regional hospital, particularly in the assessment and facilitation of continuing care cases. Tools used include value stream mapping, standardized work instructions, and error proofing through checklists, visual controls, and improved data entry procedures. The greatest benefits are derived through identifying and eliminating wastes in the process, such as wasted motion and wasted time. Other benefits occur due to the prevention of errors and reduction in the length of stay, which ultimately leads to greater customer satisfaction for both patients and employees. ex-CEO of ALCOA, Inc. started the Pittsburgh Regional Healthcare Initiative which teaches Toyota Production Techniques to healthcare workers. Non-profit hospital board members with manufacturing experience now often recommend lean to hospital administrators. [6] Although some management professionals argue that lean manufacturing does not translate well to service industries, Bowen and Youngdahl show how it does apply to healthcare by providing theory, case studies, and context for lean applications. [7] Lluis Arbos details the differential characteristics between service and manufacturing systems, such as low flexibility due to high specialization, and demonstrates how to apply lean given these differences. [8] The literature review found lean techniques applied to ordering systems, lead time and throughput, bed availability, linen distribution, waiting rooms, admissions, and discharges. Misconceptions exist concerning lean in healthcare when practitioners associate the term with lean staffing and thus, show apprehension related to layoffs and staff reduction. [1], [5] In actuality, one of lean healthcares main principles is job security, so this apprehension is misguided with proper implementation. In addition, hospital staff members do not like to be compared to assembly line workers or to have their work environments compared to factories. Executives and hospital managers must sometimes visit manufacturing facilities to see how the Toyota Production System works, and begin to visualize the potential impacts. [6] Some of the metrics for performance improvement in hospitals are: direct care percentage by unit nurse [2], number of forms to complete for a work process [3], overpayment for hospital services by insurers [3], patient length of stay (LOS) [5], number of infections per 1,000 patient days [6], and number of complications [7]. For an emergency room, the metrics found were: number of doctor visits with the same patient, average patient waiting time, the doctors direct treatment time percentage, direct care percentage by a unit nurse, orderly movement time percentage, patient throughput time, and value added time. [2]

Introduction
Lean techniques were applied to the Continuing Care (CC) services at a non-profit, full-service New England hospital. CC provides patients and families with social, emotional and educational support to deal with medical conditions, treatment, recovery and safe transition between care environments. This unit of CC coordinators and a part-time administrator serves approximately 4800 patients annually. CC reports to the Director of Quality and plays an important role in service delivery and customer satisfaction. The integration of this unit with the quality function of the hospital demonstrates the impact of continuing care services on patient outcomes and overall delivery of quality care.

Literature Review
Womack and Jones first proposed how lean techniques could be applied to services and specifically, healthcare, in their book, Lean Thinking. [4] They explain that hospitals have emphasized efficiency and high utilization rates of expensive resources, instead of organizational effectiveness. By focusing on flow in the value stream of services, Womack and Jones show how organizations can improve. Since then, many applications of lean in healthcare have been published in academic journals [7] [8] [9], trade journals [1] [3], business news [5] [6], and on hospital or consultant websites. [2] Paul ONeill, ex-Secretary of the United States Treasury and

Hospital Level Value Streams

A hospitals facility is usually similar to a process or job shop with departments organized by function. Typically, patients flow through a hospital as they move

from one department to another to obtain certain procedures. Stabell and Fjeldstad characterize a hospital as a Value Shop, according to organizational behavior frameworks and characteristics. [9] They differentiate a value shop by explaining that its primary activities are characterized by problem-finding and acquisition, problem solving, variety in choices, and repetitive control and evaluation. The order of application of resources and activities vary according to the requirements and activities at hand. Because all patients receive unique treatments, patients must be categorized by groups of patients with relatively similar value streams and flow paths. One-piece flow occurs in hospitals because batching usually only occurs at the laboratories. Flow is push instead of pull because healthy patients can not be inventoried and stored at queues within the process. However, operations could take place just-in-time with proper lean implementation. Imbalanced, variable flow issues in hospitals include the non-deterministic nature of patient arrivals, patient processing times and patient outcomes. This large variation usually causes difficulty in operating and planning effectively. Non-Deterministic outcomes for patients leads to frequent, recursive patient interviews and physical condition checks. Quality performance is monitored using internal and external customer satisfaction surveys. This variation is best handled by building flexibility into a system. Because
CC Department Level Activities Wait # 1 Identify Patient for CC Wait # 2 CC Assesses CC Patient Status & Needs Wait # 3 Assign a Level of Care Wait # 4 Create & Review Discharge Plan Wait # 5 Implement Discharge Plan Wait # 6 Reassess Discharge Plan Periodically Wait # 7

tasks are highly regulated and performed by highly specialized and often unionized employees, staff flexibility and cross-training can be just as difficult to implement in a hospital environment as in manufacturing.

Continuing Care Value Streams

After being admitted and treated, discharged patients may have a wide range of needs. In the most simple case, a physician gives a discharge order and a nurse completes documentation in the medical record and informs the patient that they can leave on their own with self-care instructions or follow-up referrals. In cases where patients require further medical attention, equipment, or home services, CC takes responsibility for discharge planning. CC activities can occur simultaneously with treatment and rest until the physicians discharge order is given, after which time the value stream is entirely in the hands of CC. The current state analysis in Figure 1 shows significant waste where an average of 180 minutes is spent discharging the patient after the physicians order is given, of which 165 is non-value added. The post-discharge order activities are further analyzed on the second table in Figure 1. The suggestions for improvement, detailed below, are expected to reduce the time from 180 minutes to 15 minutes by either eliminating waste or moving processes off-line and out of the critical path.

A*

NVA

VA

Post Discharge Order Activities Pull CC Patient File and Perform Checks

Current NVA VA Curent Total Removed

New OnLine

OffLine

720 1 240 25 1 12 1 15 1 35 2880 30 1200 165 5043 165 5208 15 133 133

9 15 3 11 90 0 0 0 0 10
138 2.30 0.10

1 0 2 1 0 1 10 20 5 2
42 0.70 0.03

10 15 5 12 90 1 10 20 5 12
180 3.00 0.13

9 15 3 11 85 0 10 20 0 10

1 0 2 1 5 1 0 0 5 0
15 0.25 0.01

10 20 2
32 0.53 0.02

Complete Remaining Tasks Alert Patient Alert Transportation Wait for Transport Alert Family Arrange Supplies Process Documentation Patient Leaves with Docs AA Records Stats and Files

Minutes Hours Days

Perform Discharge Once Order Given Minutes Minutes

*A is Treatment, Rest, and Wait Time ** NVA is Categorized Non-Value Added Activity ***VA is Value Added

Figure 1. Value and Non-Value Added Activities in the CC and Post-Discharge Order Processes

Post Discharge Order Process

Analysis of the post discharge order process began by building a complete flow chart and value stream map. Portions of the flowchart used are shown in Figure 2. Based on this analysis, the following areas for improvement and waste elimination were identified: (1) Transportation & Communication, (2) Materials Staging and Management, (3) Quality Assurance: Services & Equipment, and (4) Final Documentation Processing. One purpose of these improvements is to reduce the time from when the discharge order given by the physician to when the patient physically leaves. This frees up beds more quickly and improves the service quality and customer satisfaction. It also results in less work for CC Coordinators on the day of discharge and a more balanced workload. Currently a CC coordinator must wait until a physicians discharge order is given to arrange for patient transportation. The CC unit should negotiate better agreements with the transportation suppliers in order to receive quicker response. An intent to discharge notice could be given the day before a planned discharge in order to better plan resources. The hospital should push lean and JIT concepts to the transportation suppliers. There is currently a beeper service used for maternity patients which should be extended so that CC coordinators can facilitate quick discharge of patients who will be picked up by family members, for an inexpensive gain.

Improvements in materials management can occur by staging take-home items off- line the day before the expected discharge. The 5S technique from lean manufacturing should be used for each of the supply closets in the hospital units. The steps for 5S implementation are: seiri (sort) separate the necessary and unnecessary items and discard the latter seiton (set) neatly arrange and identify things for ease of use seiso (shine) thoroughly clean and clear the workplace seiketsu (standardization) develop regular work procedures for the first 3 Ss shitsuke (sustain) have employees make a habit of maintaining the workplace Once unneeded and outdated materials are removed from the supply closets on each unit, and the remaining items are well organized, there will be space for impending patient discharge packets. CC can use visual displays and controls to perform quality checks of the pre-staged items. Currently there are no quality assurance techniques to ascertain whether all services, equipment and transportation is arranged, or that the patient has received all necessary post-discharge information. Standardized Work, Error-Proofing, Visual Displays and Controls, and a streamlined data entry and reporting process will reduce errors and waste in the documentation process.

PHYSICIAN GIVES DISCHARGE ORDER (IN MEDICAL RECORD)

FLAG THE PATIENT FILE IF THE PATIENT IS A CC PATIENT (COLORED FLAG)

MEDICAL RECORD

NO PHYSICIAN DISCHARGES PATIENT FORM (851) IS PATIENT A CONTINUING CARE PATIENT?

YES

FORM 851 NON-CC PATIENT DISCHARGE FORM

PULL CC PATIENT DOCUMENTS

1 CC PATIENT FILE ON EACH FLOOR

PERFORM CHECKS: SERVICES DOCUMENTS INSURANCE

CREATE A DISCHARGE CHECKSHEET FOR SERVICES DOCUMENTS AND INSURANCE

NO COMPLETE ANY REMAINING EXTERNAL SERVICE ARRANGEMENTS, DOCUMENTS OR INSURANCE CHECKS EVERYTHING COMPLETE? CC PATIENT FILE

YES

ALERT PATIENT OF DISCHARGE

COORDINATE TRANSPORTATION

CC PATIENT FILE

Figure 2. A Section of the flowchart of the Post-Discharge Order Process

Standardized Work
The CC manual previously had 45 procedures: one that detailed the department policy, seven that detailed major steps in the value stream of patients, and the remainder giving regulations and instructions on how to perform each of the major steps. Many of these procedures contained redundancies or conflicting information, and they were not well ordered or organized according to the flow of CC patients through the hospital system. The procedures were most likely not well-written or organized in the past because CC had never flowcharted or mapped its processes. The seven main procedures were reorganized and structured to match the activities, tasks, and procedures identified in the new value stream maps. A detailed written procedure was also added to explain how to process CC patients once a discharge order is given, which did not exist before. The results of this work standardization should: reduce variability in job performance, reduce the risk of performing tasks incorrectly, aid in CC coordinator training, facilitate future procedure updates, and ensure procedures are performed in adherence to state and federal regulations. Now all of the CC methods and procedures have been reorganized into one document that follows the value stream map. Future use of the value stream maps, flowcharts, and new procedures will aid in understanding CC work processes and enable further waste elimination in the patient value stream.

Application of Other Lean Techniques

The hospital already employs some lean techniques, although lean has not been fully implemented. The majority of these are visual controls, but some error proofing, continuous improvement, and standardized work are also used. Even though error proofing is used widely in medicine, this department relies primarily on judgment and memory while delivering services. Each morning CC prints a master list of patients, identifies new patients, and prints a cover sheet for each and sorts them into hospital care unit folders. The left side of the folder holds documents for patients who are ready to be discharged, and the right side has forms for all other patients. It is the responsibility of the CC coordinator to track the forms and services for patients on the wings to which they are assigned. There is no good method to see which documents in the folders belong to specific patients or for confirming that all pertinent forms have been completed without going through the entire stack and reading information on each sheet.

A defect occurs when a form is not completed or a service is not offered to a patient who needs it. Over-processing occurs when a service is offered to a patient more than once. Flipping through the care unit folders results in wasted motion and over-processing while the patient is left waiting, which leads to inefficient use of the care unit room. Since there is a long list of possible services and forms specific to each patients situation, training new CC coordinators or substituting for absences is difficult. In order to minimize or eliminate some of the identified waste, a patient information (PI) Checklist was developed to track the status of tasks and required forms. The checklist had to be simple, visually organized, complete, and easy to read and understand. The most important requirement was a standard format that would work for all patients, regardless of insurance or post-discharge destination. Section one of the final checklist is the only place that requires written information. After looking at the patients medical record and meeting with the patient, the CC coordinator checks the box next to any service that might apply to that particular person. As care continues during the patients treatment and discharge process, the box in the Discussed Options, Distributed Info and Arranged Service columns are checked. If after discussing the service, the patient does not want to have it arranged, there is a Service Declined column. The first seven services on the list are those most commonly offered to patients and the rest are listed alphabetically. A CC coordinator can quickly assess the status of services by taking a quick perusal of the PI Checklist. The PI Checklist summarizes the documents that exist for a patient and the services performed, but problems exist in keeping the forms organized in the care unit folders. For this purpose, care unit binders have been designed which prevent forms from being misplaced, ensures that patients receive all necessary services, and reduces the time for CC coordinators to find information. In the new binder, one pocket folder correlates to each room on the care unit and holds all of the forms pertaining to that patient with the new PI Checklist at the front. Room number tabs on the pockets provide quick access to each patients paperwork. As patients receive discharge orders, the CC coordinator places a removable colored flag on the pocket to indicate that the paperwork can be processed and the priority for discharge. The use of these standardized binders along with the PI Checklist enables one CC coordinator to cover for another, adding staffing flexibility.

Continuing Care Statistics

The CC administrative assistant reports statistics to hospital administrators, which includes a summary

of the dispositions of discharged patients during the previous month sorted by facility type, specific facility, type of coverage, and the discharging unit. Problems that exist with the current reporting process include over-processing waste by entering unnecessary information, manually calculating totals for each category, and transferring the list and totals to a word processing program for final report creation. Problems with the database itself include an inability to update the list of facilities or services and the nonexistence of a query and reporting function. The CC monthly reporting process was improved by creating a database application that mirrors the newly designed Patient Information (PI) Checklist. Each patients necessary information is taken entirely from the checklist with dropdown lists to facilitate data entry. The database is designed to minimize user errors by tightly controlling fields while allowing for the addition of new facilities and services. The application can automatically query, summarize, and calculate the statistics for the monthly report. In the future, the portion of the checklist that details the services provided to each patient could be added in the database so that the use of CC services could by analyzed by administrators.

system that was developed has been utilized to improve quality and simplify and shorten the discharge process, using principles of error-proofing and visual displays. The database program and interface was further customized by the hospitals programmers to improve the data reporting method. The ultimate goal of this lean healthcare implementation was met by reducing the time needed to discharge a patient, while simultaneously improving quality and customer satisfaction, and also simplifying the workload and improving the job for the Continuing Care coordinators. This project demonstrates that lean techniques can be effectively implemented in hospitals and that waste can be eliminated in the patient value stream.

References
[1] Leah L Curtin. 1997. Lean, mean and stupid! Nursing Management. 28 (5): 7-9. [2] Laubrass Inc. Timely Care. www.laubras s.com/uploads/documents/corpinfo.article/ [3] Patricia Panchak. 2003. Lean Health Care: It Works. Industry Week 252 (11): 34-40. [4] James P. Womack and Daniel T. Jones. 1996. Lean Thinking. New York: Simon & Schuster. [5] Lucette Lagnado. 1997. Nearby Clinic Thrives on Streamlined Approach. Wall Street Journal February 12, 1997: B1. [6] Bernard Wysocki Jr.. 2004. Industrial Strength: To Fix Health Care, Hospitals Take Tips From Factory Floor; Adopting Toyota Techniques Can Cut Costs, Wait Times; Ferreting Out an Infection; What Paul ONeills Been Up To. The Wall Street Journal. April 9, 2004: A1. [7] David E. Bowen and William E. Youngdahl. 1998. Lean service: In Defense of a ProductionLine Approach. International Journal of Service Industry Management 9 (3): 207. [8] Lluis Cuatrecasas Arbos. 2002. Design of a Rapid Response and High Efficiency Service by Lean Production Principles: Methodology and Evaluation of Variability of Performance. International Journal of Production Economics 80 (2): 169-183. [9] Charles B. Stabell and Oystein D. Fjeldstad. 1998. Configuring Value for Competitive Advantage: On Chains, Shops, and Networks. Strategic Management Journal 19 (5): 413-437.

Conclusions
Lean techniques were implemented to improve the Continuing Care patient discharge process at a regional hospital. First, areas were targeted for waste elimination using value stream mapping. In the area of transportation, the hospital should negotiate better agreements with the providers and extend the beeper system used in other areas of the hospital for patients who are being transported by family members. On the day before discharge, an intent to discharge notice should be sent to the transportation service or family member, and materials that will be sent home should be pre-staged. The supply closets on the care units will now be better organized following the use of 5S lean techniques. The proposed checklist and binder system is intended to provide quality assurance and simplify the work responsibilities of the CC coordinators. Most importantly, these particular suggestions will help ensure that patients receive all relevant services and information during the discharge process, without duplication. The hospital can use the new database application to simplify their monthly statistics reporting, and in the future they will be able to update and add to the database system, checklists, procedures and flowcharts. Eight months after this lean initiative began, the results are evident in this hospital unit. The new procedures developed using principles of standardized work have been used in the hospitals accreditation process. The checklist and binder

Biographical Sketch
Valerie Maier-Speredelozzi is an Assistant Professor in the Industrial and Manufacturing Engineering department at the University of Rhode Island where Amy Thompson, Paul Hossfield, and Stephen Abby are all graduate students.