Redesigning a Pre-Admission Facility

Re-Design of a Pre-Admission Facility
Interactive Quality Improvement Workshop
Richard Bowry, MD Antoine Pronovost, MD Patricia Houston, MD
June 18, 2012
St. Michaels Hospital
Outline
1.
Introduction to DMAIC methodology

Case study stem 1
2.
Key concepts and facilitated discussion

stem 2
3. 4. 5.
Process mapping exercise Quantitative analysis, facilitated discussion Quantitative analysis, group work
stem 3
6. 7.
Root cause analysis didactic session Facilitated discussion: leading change what went wrong
stem 4
8. 9.
Didactic session: key success factors for implementing and monitoring change Conclusion
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Disclosures
Dr Richard Bowry
No disclosure
Dr. Patricia Houston

No disclosure
Dr Antoine Pronovost
Has received funding from the government of Ontario to study and improve Pre-admission facility processes.
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Objectives
You will understand how to apply Quality Improvement techniques to the complex problem of redesigning a PAF You will become familiar with the five stages of DMAIC You will become familiar with the key principles of successful change management
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Limitations and Caveats
We will not be providing you with a cookbook answer for fixing problems in your own PAF
Solutions take teamwork, planning and local insights to work
The case study is loosely based on actual experience, but has been heavily adapted for the purpose of this session
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Introduction to DMAIC
DMAIC - Define
Reasons for action? What are our targets? What is within our control? All members need to agree on the problem Create a purpose statement rationale, scope and targets Start an A3 style grid to monitor progress
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Define - A3
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DMAIC - Measure
What is our baseline? Acknowledge our own variation / trends? What happens 80% of the time? Root cause analysis Prioritization matrix Cause Effect Diagram
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Prioritization Grid
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Cause-Effect Diagram
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DMAIC - Analyze
What does our current state look like? Are there any wasted steps in what we do? How would a patient experience this? What are the root causes?
Process mapping to identify NVA steps Holistic approach looking at all aspects Spaghetti Charts
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DMAIC - Improve
How should the future state look? Use rapid process improvement cycles Pilot and observe Remove unnecessary steps and create a future state No need to get it perfect first time Implement pilots to assess impact
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DMAIC - Control
Re-evaluate and make ongoing changes Monitor the new performance Repeat the cycle as require to further improve Reevaluate the changes and re-design as needed Repeat evaluation of process to assess impact Ongoing performance monitoring
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Tool Matrix
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Case Study Stem 1
You have been asked to review your preadmission facility by your CMO because:
Patients are unsatisfied with long wait times Surgeons offices are frustrated they cannot access short-notice appointments
These are necessary to fill time released by lastminute patient cancellations
Staff complain of declining morale

Anaesthesiologists are reluctant to work in clinic
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2. Facilitated discussion: Key concepts and tools to address this problem
Perception shift: this is a chain, not a series of independent events Concepts:

Bottleneck Batching
Flow mapping: practicalities
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This is a process, not a series of independent events
Anne M Breen, Tracey Burton-Houle, David C Aron,Applying the theory of constraints in health care: Part 1-- the philosophy, Quality Management in Health Care; Spring 2002; 10, 3;pg 40.
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If each step has a measurable capacity, what determines overall throughput?
A.
Average (13)
B.
C. D.
Highest cacapacity pacity (17)

Lowest capacity (8) Cannot answer need simulation model
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The chain must be considered as a whole, not as a series of independent events
20
Local optima dont matter !
If bottlenecks limit throughput, why not simply eliminate them?

13 13 13 13 13
Because in real life, systems need flexibility:

Ability to catch up = excess capacity Need for excess capacity increases with system complexity/variability
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So what do you do with bottlenecks?
Identify the bottleneck Elevate the bottleneck Design the process around the bottleneck
Unload the bottleneck Keep the bottleneck busy all the time
This means non-bottleneck resources MUST sometimes be IDLE.
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Batching: a very special effect on bottlenecks
Batching refers to the processing of many units in a single group, for example:
I change all the ceiling light bulbs at the same time because I need a stepladder (hard to get) Painting all similar colours together (trim, then walls, then contrast wall) Porters delivering multiple samples to the lab
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Batching: advantages and disadvantages
Pro
Cons
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Process mapping: putting it all together
Lather
Repeat
Rinse
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Flow Mapping: Common Concerns
What if I dont get it right the first time? How do I keep people focused?
How do I frame the hypothesis?
How much technical stuff do I need to know to participate or lead this discussion?
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What if I dont get it right the first time? Dont worry you wont get it right the first time Thats part of the plan Its an iterative process, and youll likely need a few drafts. Its a group process, and much benefit comes from team discussion:
Oh so thats what happens when the patient leaves my care
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Basic approach to frame the process

Set clear start and end points Follow a single patient through a standard encounter Use Post-It notes on large paper background Transcribe draft into clean computer after meeting
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How many fancy symbols do you need to master?

Terminator Defines start/end of process (only 2 per map)
Activity
Decision Flow Line
This is where work happens

a fork in the road, best phrased as yes/no question Connect steps
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3. Process Mapping exercise
Please use this time to develop a process map in small group settings Use the data from case study stem 2 (next slide) as a starting point for your process map
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Case study stem 2: Clinic details
60 patients are seen daily; Patients are registered, then seen by a nurse, then by a family doctor; 50 % of patients seen by an anaesthesiologist; Subgroups (orthopaedic and cardiac surgery) patients also receive group teaching;
Other patients receive DVD-based teaching;
Most patients receive bloodwork, and EKG +/- xray investigations while in clinic.
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Define Process Mapping Exercise
Three groups Map the current state Brief Presentation of processes found
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4. Quantitative analysis: Facilitated discussion
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Initial Thoughts
Quick Fix approach vs Root Cause Analysis

Bottlenecks Local optima vs global optimum Non-value add activity Batching
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Lessons Learned
Conventions in mapping Importance to map out whole process
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Measure
Sources of Data IT/IM Resource Presentation of information
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5. Quantitative analysis Group work Case Study Stem #3
Quantitative Data to be provided in the following slides/handouts. Please review and discuss implications of quantitative data.
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Stem #3: Quantitative Data (Continuation)
Re-Design of a
Mean Median Standard Dev. Resource Availability Throughput
RN Wait Time 13.7 min 10 min 9.9 min 8 Nurses 14.8 patients/hours
Pre-Admission Facility
RN Encounter Time 32.5 min 30 min 12.9 min
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FMD Wait Time Mean Median Standard Dev. Resource Availability Throughput 21.5 min 20 min 17.1 min 1 FMD 7.9 patients/hour FMD Encounter Time 7.6 min 6 min 3.9 min
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Anaesthesia (AN) Wait Time Mean Median Standard Dev. 27.6 min 20 min 21.9 min AN Encounter Time 12.3 min 10 min 5.7 min
Resource Availability 1-2 AN Throughput 4.9 patients/hour (1 AN)
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Stem #3: Quantitative Data (Continuation) AN wait time by scheduled time of day
Patient Ready Time vs. AN Wait time
6:00
4:48
3:36
Wait time
2:24
Acceptable Wait Time
1:12
0:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 Patient Ready Block
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Throughput balancing: find the bottleneck
Nurse Throughput: 14.8 patients/hr
FMD Throughput: 7.9 patients/hr
AN Throughput:
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Measure Data Interpretation
Wait-time and value-add times Satisfaction Capacity analysis Scheduling Variability
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6. Root Cause analysis
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Analyze Root Cause Analysis

Rework, competing priorities, and interruptions at triage slows down the overall process and adversely affects staff and patient satisfaction. Excessive waiting time along with a confusing process for patients affects patient satisfaction within the ED. Redundancy in information gathering along with seeking out information through different channels, causes delays and frustration for staff and patients. There is an increased risk for errors.
Multiple Competing Duties
Merging of Patient Information
Repetitive Collection of Pt Demo
Triage/Wtg Rm Traffic Directed by RN
Multiple Phone Calls, Interruptions Data Entry
Many ways to get info for Pt Reg
Redundancy in Validation of Patient Information
Continuous EDIS vs ADT Reconciliatn
Patient Registration Seeking Addl Info
Lack of Consistent Triage Process
Multiple Entry Points for ED Patients
Gaps in Patient Education
Multiple Competing IT Systems
Lack of Standardized Forms
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Analyze Theory of Constraints

1. Identify the Constraint
2. Exploit the Constraint
3. Subordinate everything to the Constraint
4. Elevate the Constraint
5. Repeat for the new Constraint

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Analyze Computer Simulation
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7. Facilitated discussion Case Study Stem #4: Le denouement Suggestions are implemented, but results are not anticipated
Wait times increase Throughput decreases
Morale deteriorates significantly

Staff, especially RNs leave their positions leaving unfilled vacancies Much finger-pointing/blaming ensues
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8. Key success factors for implementing and monitoring change
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Improve Stakeholder Engagement
Engage in issues that matter Use Engagement to drive decisions Engage the right stakeholders Engage empowered representatives Seek shared values Agree on the rules of engagement Manage expectations provide adequate resources
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Improve Stakeholder Engagement
What stakeholders need:

Fairness Listen Build Trust Be open Be accountable Evaluate
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Improve Change Management
Establishing a Sense of Urgency Forming a Powerful Guiding Coalition Creating a Vision Communicating the Vision Empowering Others to Act on the Vision Planning for and Creating Short-Term Wins Consolidating Improvements and Producing Still More Change Institutionalizing New Approaches
Kotter, Leading Change 1996
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Control - Sustainability
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Improve Unintended Consequences
Balanced Scorecare
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Improve Measuring Success
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Control Control Charts

CTAS 1-3 Performance (percentage met EDLOS < 8 hours) CTAS 4-5 Performance (percentage met EDLOS < 4 hours) Apr '08 to Aug '10
100 95 90 85
82 89
80 75 70 65 60 55
52 CTAS 1-3 CTAS 4-5 76
50
May-08 May-09 May-10 Nov-08 Nov-09 Feb-09 Mar-09 Feb-10 Aug-08 Sep-08 Aug-09 Sep-09 Mar-10 Dec-08 Dec-09 Aug-10 Apr-08 Apr-09 Apr-10 Jul-08 Jul-09 Jun-08 Jan-09 Jun-09 Jan-10 Jun-10 Oct-08 Oct-09 Jul-10
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Conclusion
DMAIC Methodology Stakeholder Engagement Leading Change Measuring Success Importance of Value Add
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Appendix
The following slides can serve to supplement case discussion.
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Theory of Constraints asserts that in the real world a balanced plant will self-destruct
Statistical variability: Throughput at each step varies around a mean + Dependent events: a downstream process cannot occur before its upstream precursor = Small gaps build up to infinity unless there is reserve capacity
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Consider the famous example of a group of hikers
Scouts are heading on a 5 mile hike They must walk single file
They cannot pass each other (dependent events)
Each hiker walks at a similar pace, but there is some variation

Each time a scout stumbles or slips, he loses some ground
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Diagram of the Goldratt hike

Direction of hike Start
SSSSSSSSSSSSSSSSSSSSSSS
After 1 hour
SS
SSSS SS SS SSS SSSS SSS
S S
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Conclusions from the hiking example
1. Over time, the scouts will continue to spread; 2. To keep the group compact, one must place the slowest hiker (bottleneck) at the front.
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So how do you identify bottlenecks? In the hiker example, you look for a large gap in front of a scout In a plant, you might look for a large pile of inventory in front of a particular station In a hospital, you could look for a large number of (angry looking) patients in a waiting room
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Operational management requires awareness of two key elements

Variability: Statistical variation and dependent events Bottlenecks: Bottlenecks are neither good nor bad
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Batching: a very special effect on bottlenecks
Batching refers to the processing of many units in a single group All units have the same start/finish times Batching is highly effective when setup costs/setup time are high
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Batching cupcakes:
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As a cupcake-baker, batching is great because:
I mix one batch of batter, drop it into moulds, place in the oven, and Im done; I only have to run the oven once (lower energy costs ); This is a locally optimal solution.
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As a cupcake-decorator, batching is terrible: At first, I have no work to do while the cupcakes are baking Then I suddenly have 20 cupcakes to decorate.
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How does this come together? Assume baking a batch of 20 cakes takes
15 minutes prep + 45 minutes baking
Assume decorating takes 5 minutes per cake How long would it take to make a single batch of 20?
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Answers:
A. 5 minutes/cake x 20 = 100 minutes B. 3 minutes/cake x 20 = 60 minutes C. 60 minutes + 5 minutes/cake x 20 = 160 min
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Answer is D 160 minutes
This results in cupcake cycle time of 160/20 = 8 minutes per cake That doesnt seem so bad
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When was the first cupcake ready?
60 + 5 = 65 minutes
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When was the last cupcake ready?
60+100 = 160 minutes Time for 10th cupcake 60+(10x5) = 110 minutes
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Why might this be a problem? Assume cupcakes are shipped from the kitchen in batches of 20:
What if a walk-in client wants to pickup 6 cupcakes:
It takes almost 3 hours for the first (and last) cake to be ready
What if the cupcakes sell best when they are fresh (< 45 minutes from the oven)
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What are possible solutions?

Have the cake-decorator start/finish 1 hour after the cake-baker Have a cake reserve for the decorator
buffer in operations parallel in health care: waiting room for patients
Make smaller batches

The ultimate small batch is a single unit Might reduce batch size after decoration
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What is the product at the end of the 8-hour day?
Baking 8 hours/batch x 20 cakes/batch = 160 cakes Decorating 7 hours (1 lost hour) x 12 cakes/hour = 84 cakes Total 84 finished cakes 76 waiting
June 18, 2012

Redesigning a Pre-Admission Facility

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Re-Design of a Pre-Admission Facility

Interactive Quality Improvement Workshop

Richard Bowry, MD Antoine Pronovost, MD Patricia Houston, MD

June 18, 2012

St. Michaels Hospital

Introduction to DMAIC methodology

Key concepts and facilitated discussion

June 18, 2012

St. Michaels Hospital

Dr. Patricia Houston

June 18, 2012

St. Michaels Hospital

St. Michaels Hospital

Limitations and Caveats

St. Michaels Hospital

St. Michaels Hospital

June 18, 2012

St. Michaels Hospital

St. Michaels Hospital

June 18, 2012

St. Michaels Hospital

June 18, 2012

St. Michaels Hospital

St. Michaels Hospital

St. Michaels Hospital

St. Michaels Hospital

June 18, 2012

St. Michaels Hospital

Case Study Stem 1

Staff complain of declining morale

St. Michaels Hospital

2. Facilitated discussion: Key concepts and tools to address this problem

Perception shift: this is a chain, not a series of independent events Concepts:

Flow mapping: practicalities

June 18, 2012

St. Michaels Hospital

This is a process, not a series of independent events

June 18, 2012

St. Michaels Hospital

If each step has a measurable capacity, what determines overall throughput?

Highest cacapacity pacity (17)

The chain must be considered as a whole, not as a series of independent events

Local optima dont matter !

St. Michaels Hospital

If bottlenecks limit throughput, why not simply eliminate them?

Because in real life, systems need flexibility:

St. Michaels Hospital

So what do you do with bottlenecks?

June 18, 2012

St. Michaels Hospital

Batching: a very special effect on bottlenecks

June 18, 2012

St. Michaels Hospital

Batching: advantages and disadvantages

June 18, 2012

St. Michaels Hospital

Process mapping: putting it all together

June 18, 2012

St. Michaels Hospital

Flow Mapping: Common Concerns

June 18, 2012

St. Michaels Hospital

St. Michaels Hospital