accelerating the lean six sigma transformation by engaging physicians

Accelerating the Lean Six Sigma Transformation by Engaging Physicians

WCBF’s 10th Annual Lean Six Sigma and Process Improvement in Healthcare Summit

May 10, 2011 Workshop A

David V. Chand, MD Anne Musitano, RPh, PharmD, MBOE, BB

Akron Children’s HospitalCenter for Operations Excellence

1Process improvement through people development™

Copyright Children's Hospital Medical Center of Akron

Agenda

Overview of ACHBrainstorming exercise and discussionResident Education Radiology JourneyBreakPractical exerciseTakeaways

Process improvement through people development™Copyright Children's Hospital Medical Center of Akron

Overview of Akron Children’s Hospital


Akron Children’s Hospital

• Largest pediatric healthcare provider in Northeast Ohio.• 2 Freestanding pediatric hospitals & services in 80+ locations

across the region• 253 bed• ½ million patients each year • 4,000 + employees• 10,000 admissions • 579,000 outpatient visits• Gold Seal of Approval from the Joint Commission • Magnet Recognition Status from American Nurses

Credentialing Center


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Akron Children’s HospitalCenter for Operations Excellence

Center for Operations Excellence:• The mission of the Center for Operations Excellence is to

develop and use in-house talent to improve the healthcare experience of our patients and families, while improving the working experience of our staff.

• Currently staffed by 8 individualso 1 Senior Directoro 5 project leaderso 1 data analysto 1 office coordinator


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Philosophy of the Center for Operations Excellence

Process Improvement Through People Development TM


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•A3•Green Belt•Black Belt•Blue Belt•Kaizen

Akron Children’s HospitalLean Six Sigma Operating System


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Benefit Category Since COE inception (as of February 2011)

Patient wait time reduced (days)

42,831

Staff non-value added time reduced (hours)

24,056

Appt access times reduced (days)

74,608

Financial Impact (directand indirect)

$8,177,222

Akron Children’s Hospital’s Lean Six Sigma Operating System

• A3: 8-week formal training program which teaches front-line staff the basics of Lean, culminating in the completion of a project in the participant’s home department.


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• Green Belt: Formal training program and project which lasts 6-12 months, following the DMAIC (Define, Measure, Analyze, Improve, Control) format.


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• Black Belt: 12-month projects involving large value streams which utilize more advanced tool of Lean Six Sigma via OSU.


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• Blue Belt: Training for managers and departmental leaders focusing on daily management in a Lean enterprise through tools, processes, and systems.


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• Kaizen: Events lasting 2-5 days which result in rapid implementation of countermeasures.


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Brainstorming Exercise

When you think of engaging physicians in a Lean Six Sigma transformation, what potential barriers to success have you encountered in your organization?

Please list them and be prepared to share with the audience


Green Belt Project:Resident Rounding


Goals

• Review a green belt project from start to finish and understand how to involve physicians

• Realize the importance of engaging physicians-in-training to cultivate a lifelong attitude of continuous improvement

• Identify the key success factors necessary for successful engagement of physicians in Lean Six Sigma projects


DEFINE


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Center for Operations Excellence

Project CharterProblem Statement:Residents are currently limited to working a maximum of 80 hours per week, and this limit will likely be reduced to 55-60 hours in the next 2-3 years. In order to provide excellent patient care and drive educational value, the entire resident rounds process, which comprises roughly 50% of the day, must be improved in terms of efficiency so as to maximize value-add time during their work day.

Goal Description:Reduce the non-value-add time per patient (including necessary non-value-add time) present in the pre-rounding and rounding process from 66% to 50% (25% reduction) in 9 months.

Scope:In Scope: 7:00 AM-12 Noon on weekdays for the Green Team Hospitalist service only. Only those activities related to the pre-rounding and rounding process

Benefits:

Reduced time spent roundingOpportunity for attendings to do bedside teaching and role modelImproved nursing morale/satisfactionImproved patient/family satisfactionBetter communicationPotential reduction in length of stayPotential earlier times of discharge

Project Y: Key Metrics:Non-value add (NVA) time (including necessary NVA): includes time not spent with patient/family which does not contribute directly to diagnosis/treatment/discharge

•Survey results pre- and post-intervention (resident, attending, nurses, and families)• time per patient

Team Members: Stakeholders:•Champions: M. Ramundo, MD, and N. Christopher, MD•MBB: Laura Winner, Johns Hopkins•Green Belt: David Chand•Process Owner: David Chand and Chief Residents•Team comprised of residents, attendings, nurses, and parent advisory council rep

ResidentsAttending physiciansNursesPatients and FamiliesMedical students

MEASURE


Feedback appears to focus on making communication efficient and visible, as well as an emphasis on developing a clear management plan

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Attendings

Residents

Nurses

Parents

“We need to focus on

diagnosis and management”

“There should be fewer handoffs”

“Smaller teams would allow for better teaching and efficiency”

“More bedside contact with

patients”

“Order entry during rounds”

“Need to follow a schedule—too

much time waiting around”

“Involve interns in forming plans

and focus on management”

“More bedside contact with

patients”

“Physicians seemed very

rushed”

“We need better communication

and legible notes”

“I didn’t even know resident

rounds existed”

“Attendings and residents should round with the

nurse”

“There should be a scheduled time

for rounds”

Source: DRG Attending, pediatric resident, nursing, and patient family surveys administered Fall 2008

“More communication from docs on plan of care”

Sample observation data

The current Value Stream Map (VSM) for each resident is comprised of three major steps composed of several sub-processes

21* Currently, there is no predetermined sequence of events. There is wide variation in the order in which these sub-processes are performed.** 5 rounding sessions covering 88 total patients, including 23 primary patients covered by the observed residentsSource: Resident rounds observation data, Fall 2008

The majority of time is spent in formal educational activities, note writing, and formal sit-down rounds

0:00

0:15

0:30

0:45

1:00

22

Average time spent during each stepTime (hours:minutes); N=5*

* 5 rounding sessions covering 88 total patients, including 23 primary patients covered by the observed residentsSource: Resident rounds observation data, Fall 2008

However, only 17% of time spent can be classified as value-add

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Average time spent by value contributionTime (hours:minutes); N=5*

Percentage of total time by value contributionPercent; N=5*

•While only 17% of time is value-add, most manufacturing industries recognize that only 10% of their activities are value-add•Opportunity still exists to drive this percentage higher


240.0750.0600.0450.0300.0150.000

LB USL

LB 0Target *USL 0.01042Sample Mean 0.0140399Sample N 23Location -4.44952Scale 0.43071

Process DataPp *PPL *PPU -0.01Ppk -0.01

O v erall C apability

PPM < LB 0.00PPM > USL 565217.39PPM Total 565217.39

O bserv ed Performance

PPM < LB *PPM > USL 566075.96PPM Total 566075.96

Exp. O v erall Performance

Process Capability of achieving non-value added time within 15 minutes pr ior to Improve (Oct 2008 - Dec 2008)

Calculations Based on Loglogistic Distribution Model

Current state capability:Non-value-add time per patient


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Spaghetti Diagram: Current State


ANALYZE


Most of the waste can be classified as either inventory or overprocessing

0:000:150:300:451:001:151:30

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Average time spent by type of wasteTime (hours:minutes); N=5*

Percentage of total time by type of wastePercent; N=5*

•40% of the waste is described as inventory, in which patient information is available but is not acted upon—in other words, it is “stored” to be used later•32% of the waste is classified as overprocessing, in which unneeded steps are taken to complete a task


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Average rounding time per patient of 31 minutes

Cause & Effect (Fishbone) Diagram

Measurements Material Personnel

Environment Methods Machines

Patients/Families

Residents

Attending physicians

Nurses

Physical layout

Seasonal effects Note writingClinAcc

Paging system

XWebOrders

Charts

Presentation format

Students

Education schedule

Work hours

Signout process

Order sheets

Fax machines

Ancillary services

RECS

Discharge times

Pre-rounding

Formal rounds

Areas of focus

Patient assignment by age

IMPROVE


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Center for Operations ExcellenceEase Impact Chart

Easy to implement Difficult to implement

Low impact

High impact

Use of takt time

Integrating education into roundsCollaborative

exam and note

“Family Centered Care” on all patients

SWI for presentations

Including nurses in rounds

Orders written during rounds


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Takt time calculator


Time directly with patients and families now comprises the majority of residents’ time

0:00

0:15

0:30

0:45

Family C

entered C

are/Educatio

nAdminist

rative

WalkingPersonal

Signout

Physician

Inter

actio

nData C

ollectio

nMS3 I

nterac

tion

Waiting

Average time spent during each step, post-interventionTime (minutes); N=5*

* 5 rounding sessions covering 86 total patients, including family-centered care for 8 primary patients covered by the observed residentsSource: Resident rounds observation data, Spring/Summer 2009

55% of time spent can now be classified as value-add

26%

55%

19%

NNVAVANVA

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Average time spent by value contribution, post-interventionTime (minutes); N=5*

Percentage of total time by value contribution, post-interventionPercent; N=5*

The proportion of value-add time has been more than tripled by reducing redundant work and increasing time directly spent with patients and their families

* 5 rounding sessions covering 86 total patients, including family-centered care for 8 primary patients covered by the observed residentsSource: Resident rounds observation data, Spring/Summer 2009

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0 .0100 .0080 .0060 .0040 .0020 .000

LB U SL

LB 0T a rge t *U S L 0.01042S am ple M ean 0.0046875S am ple N 8Loca tion -5 .40504S ca le 0.192574

P rocess D a taP p *P P L *P P U 0.51P pk 0.51

O v e ra ll C apability

P P M < LB 0.00P P M > U S L 0.00P P M T ota l 0.00

O bserv ed P e rform ance

P P M < LB *P P M > U S L 12527.37P P M T ota l 12527.37

E xp. O v e ra ll P e rform ance

P r o ce ss C a p a b ility o f a ch ie v in g n o n -v a lu e a d d e d t im e in R o u n d in g w ith in 1 5 m in u te s in P o st-I m p r o v e ( J u n e 2 0 0 9 )

Calculations Based on Loglogistic Distr ibution Model

Pilot phase capability:Non-value-add time per patient


Notes

Signout Morning Report

CT Min1

Batch Pts10-21

CT Min30

Option %60

7:00 A.M. 8:00 A.M. 9:00 A.M. 10:00 A.M. 11:00 A.M.

Total Min24

Option %100

Lecture

CT Min45

Option %60

Lean Family-Centered Care*

Activity Option (%)CT (Min)*

Family-Centered Care 10010

Walking 1002

Administrative 1003

Clinical Care


Data collection 10011

Physical exam 1005

Family interaction 906

Physician interaction 509

Nursing interaction 201

Orders 5010

Note writing 10015

Non-Value-Add and Necessary Non-Value Add

Value-Add

2 Min 30 Min 10 Min 45 Min30 Min20 Min

32 Min

28 Min

10 Min

40 Min

Notes

Discussion during rounds may force the

resident to complete further

activities in the clinical care

arena

* Lean Family-Centered Care includes talking to the family, examining the patient, and discussing the plan of care with the attending, intern, and nurse present. During the “Administrative” step, notes and orders are written ** Cycle times for Clinical Care refer to the average total time spent in each activity, although they may occur during two distinct time periods during morning rounds

Examples of Waste:Walking Notes and order writing

Examples of Waste:Patient hand-offs

Examples of Waste:Illegible notesWaiting for available computersSearching for charts

Batch Pts1-4

Batch Pts1

Process is repeated for each patient

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Center for Operations ExcellencePilot Phase VSM


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Spaghetti Diagram: Pilot Phase


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Center for Operations ExcellenceProject Results

Measure Before Goal After % change

Average rounding time per patient*

Average value-add time*

Average non-value-add time*

31 minutes

10.9 minutes

20.2 minutes

15 minutes

8.3 minutes

6.8 minutes

52% reduction

24% reduction*

66% reduction

23.5 minutes

≥ 10.9 minutes

15.1 minutes

*The reduction in value-add time is likely due to several factors:• Improved speed of talking to families and conducting physical exams with experience• Using the traditional method, residents often returned to patients’ rooms more than once to clarify information, convey plans, and answer questions which were eliminated using Lean Family Centered Care

•Only includes time spent on a specific patient (i.e., does not include formal education time, personal time, etc.)Source: Resident rounds observation data, Spring/Summer 2009

The newer model facilitates teaching and mentoring by attending physicians

0 1 2 3 4 5

PostPre

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The rounding process provides me with adequate time to reach my personal teaching goals.After morning rounds, residents have a firm understanding of the plan of care for their patients.The current pre-rounding process allows me to use my time effectively.***The rounding process allows me to use my time effectively.

The information conveyed by the residents during formal rounds helps me in developing my plan of care for each patient.I have the opportunity to coach residents and provide timely feedback with regards to their physical examination.I have the opportunity to coach residents and provide timely feedback with regards to their assessments and plans.

The process provides residents with adequate time to complete patient care duties prior to attending noon conferences.

The current role of 3rd year medical students in rounds promotes efficiency.

Hospitalist survey*, pre-intervention, N=5 and post-intervention, N=2**

* 1, Strongly Disagree; 2, Disagree; 3, Neutral or no opinion; 4, Agree; 5, Strongly agree** None of the differences in responses seen pre- and post-intervention were statistically significant*** There is no pre-rounding process in the Lean Family-Centered Care modelSource: DRG Attending survey administered Fall 2008 and Spring/Summer 2009

Residents felt the new model promoted efficiency, quality patient care, and education

0 1 2 3 4 5

PostPre

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I find the current signout to be useful when I am on-call.

I find that writing a daily progress note is an educational experience.

I receive adequate coaching and feedback from attendings.

I am satisfied with the teaching/education I receive during rounds.

My time is used efficiently during pre-rounds**.

My time is used efficiently during rounds.

After morning rounds, I feel that I have a firm understanding of the plan of care for my patients.

I am satisfied with the amount of time I interact directly with patients and their families.

I am given the appropriate amount of autonomy to manage my primary patients.

Pediatric resident survey*, pre-intervention, N=37 and post-intervention, N=11

I am efficiently able to obtain patient data from the current on-line system.

The formal rounding process promotes quality patient care.

I am satisfied with the way morning rounds are conducted.

The rounding process allows me to achieve my personal goals (e.g., patient care, teaching, etc.)

* 1, Strongly Disagree; 2, Disagree; 3, Neutral or no opinion; 4, Agree; 5, Strongly agree** There is no pre-rounding process in the Lean Family-Centered Care modelSource: Pediatric resident survey administered Fall 2008 and Spring/Summer 2009

Nurses significantly favored the newer model and felt that they were more involved in the plan of care

0 1 2 3 4 5

PostPre

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Following resident morning rounds, I am aware of the plan of care for each of my patients.

Physician orders are presented to me in a way that allows me to act upon them in a timely fashion.

I am able to gain a clear understanding of the patient’s plan of care from the primary team’s notes in the chart.

The resident rounding process allows me to plan my work day appropriately.

Nursing survey*, pre-intervention, N=48 and post-intervention, N=6

I believe that my patients’ parents or guardians understand the daily plan of care.

The resident rounding process occurs in an efficient manner.

* 1, Strongly Disagree; 2, Disagree; 3, Neutral or no opinion; 4, Agree; 5, Strongly agreeSource: Nursing survey administered Fall 2008 and Spring/Summer 2009

The survey did not detect significant changes in families’ attitudes towards the process

0 1 2 3 4 5

PostPre

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I know that I can participate in morning rounds with my child’s health care providers.

I know approximately what time my physicians will be in to see my child and me.I am satisfied with the amount of time that physicians spend with my child and me each day.

My child’s physicians take enough time to answer my questions each day.

I understand what needs to occur before my child can be discharged from the hospital.

I am satisfied with the quality of physician care provided.

I am satisfied with the coordination of care provided.

I feel my input is valuable to the team when I can participate in rounds.

Patient family survey*, pre-intervention, N=33 and post-intervention, N=15

I would be interested in participating in morning rounds with my child’s health care providers.

Following morning rounds, I understand the plan of care for my child.

I understand the role of each of the health care providers involved in my child’s care.

* 1, Strongly Disagree; 2, Disagree; 3, Neutral or no opinion; 4, Agree; 5, Strongly agreeSource: Patient family survey administered Fall 2008 and Spring/Summer 2009

Signout Education

CT Min1

Batch Pts10-50

CT MinTBD

Option %100

7:00 A.M. 8:00 A.M. 9:00 A.M. 10:00 A.M.

Total Min60

Option %100

Lean Family-Centered Care



Walking 1002

Administrative 1003

Notes

The Future State

Batch Pts1

12:00 P.M.11:00 A.M.

Standardized work instructionsPatients distributed to interns based on volume, complexity, and locationTakt time calculator used to plan rounding process

Process is repeated for each patient

Lean Family-Centered Care



Walking 1002

Administrative 1003

Batch Pts1

Process occurs in parallel with 2-4 attending physicians based on total patient volumeContinuous one-piece flowSmaller “sub-teams”Education integrated into processSWI for presentations

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Center for Operations ExcellenceFuture State VSM—Vision for the Future


CONTROL


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3128252219161310741

00:50:00

00:40:00

00:30:00

00:20:00

00:10:00

00:00:00

Patient Observation

NonV

alue

Add

ed T

ime

(hh:

mm

:ss)

_X=00:06:45

UCL=00:13:58

Pre-Improve (Oct 2008 - Dec 2008) Post-Improve (June 2009)

2

2

I Chart of Non-value added time by Stage (with Stability)

Pilot Phase Control chart:Non-value-add time per patient


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Center for Operations ExcellenceControl Plan

Measure TargetFrequency of monitoring Responsibility Threshold Reaction plan

Use of takt time calculator

100% of time

Weekly Senior residents 80% of time Education

Time per patient

15 minutes Monthly observation

David Chand 20 minutes •Real-time coaching•Review of SWI

•Monitoring is currently a challenge as it relies on direct observation and manual data collection•In the future, we will randomly audit the process monthly by asking a third-year medical student on the team to track the time spent per patient during the process


Key Success FactorsFrom this project, we learned the importance of the

following:• Utilization of the Voice of the Customer (VOC)• Picking a project that addresses a significant “pain point”

for physicians—identifying the “burning platform” for them• Emphasis on the similarities between DMAIC and the

Scientific Method• Importance of data/observation: “going to the gemba”• Selection of a multidisciplinary project team• Recognize the opportunity to involve physicians-in-training

to instill a commitment to continuous improvement


Radiology’s Journey to Providing

Exceptional Radiology Services

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Center for Operations Excellence


Goals

• Review the journey of Radiology from 2008 until present, focusing on the increasing involvement of physicians.

• Identify the key success factors necessary for successful engagement of physicians in Kaizen projects and Daily Management Systems (ACH Blue Belt Program)


A3 projects 1/09 – Present • 13 projects to date- Inventory, layout, patient wait time, imaging quality

Green Belt Project 2/9/09 - 6/22/09• Stabilized schedule and built capacity to allow for IP & OP’s

Shelly’s A3 Project 7/22/09 – 10/12/09• Figured out how to best populate and manage the schedule by working with the schedulers

MRI Kaizen 8/20/09 – 8/21/09 & Continued follow-up • Radiologists, technologists, managers, and the ARC team worked together to develop system to pull patients forward to load the daily schedule and improve access times of patients needing an MRI.

Blue Belt Program 9/10/10 – 4/30/11- Daily Management System


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The Lean Journey of the Department of Radiology

Radiology- 13 staff members A3 trained!


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Joanne: Improving X-ray verification step

Nichole: Improving the patient care supply areas

Radiology Involvement in 2 Kaizens!

• Kaizen: Events lasting 2-5 days which result in rapid implementation of countermeasures


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Dr. Rubin, Dr. Eghbal, Jason, Marie, Carol, Terry, Shelly, Julie, Tina, Kim: Reducing MRI patient access times to outpatient appts by increasing weekly exams performed

Sedation Services, Radiology, & others: Improving the utilization of Sedation Services through balancing & coordinating the schedule between departments

Sustainability of MRI Kaizen!


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Key Success Factors for Kaizen

From this project, we learned the importance of the following:

• Focusing on the system- look at the entire value stream• Defining the physician role in projects- remove barriers,

ask questions, look at & verify the data • Providing brief and consistent updates of the project status• Having solid and plentiful data (e.g. utilization rates)• Presenting the successes to peers, the Hospital Board,

and PI groups


Blue Belt Training:Radiology Department


The Elements of the Daily Management System: People, Tools, and Systems

1. People‐ Coaching & Idea Board

2. Tools‐ Daily Metric Boards, Daily Huddles, Value Stream Mapping, DOWNTIME waste, 5S, Idea Board

3. System‐ Leader Standard Work, Problem Solving, Gemba Walking

IDEA BOARDS THROUGHOUT RADIOLOGY


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Tools- Value Stream Mapping, Fishbone, Visual Management


METRIC BOARDS- Visibility! Quality, Growth, Research, Brand

57Process improvement through people development™Copyright Children's Hospital Medical Center of Akron

Daily Huddles


Go to the Gemba and See!Ask questions to Learn!


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Takeaways from ACH

• Focus on the benefits from quality perspective• Data• Pick a project that addresses a significant “pain

point” for physicians• Identify the “burning platform” for them• Demonstrate the wins

• Utilization of the Voice of the Customer (VOC)-put parents on teams!

• Interdisciplinary teams to solve problemsProcess improvement through people development™

Copyright Children's Hospital Medical Center of Akron

Physician Skill-set Needed for Current Conditions of Healthcare

• Leadership skills- transparency, coaching, visibility, and team oriented approach to meet operational and quality goals

• Creating a vision for the respective department (s) that aligns everyone towards the same goal

• Focus on the patient – daily if possible • Patience to trial countermeasures


About the Presenters• David Chand is a pediatric hospitalist and Lean Six Sigma Project Leader at Akron Children’s

Hospital. Prior to joining the staff at Akron Children’s Hospital in 2008, David worked for two years as a business management consultant for McKinsey & Company, focusing on growth strategy and operations for healthcare providers in the U.S. and Canada. He earned his B.S. and M.S.E. in Biomedical Engineering from The Johns Hopkins University and then his M.D. through the Health Sciences and Technology program at Harvard Medical School and The Massachusetts Institute of Technology. David completed his residency and chief residency in pediatrics at Rainbow Babies & Children’s Hospital in Cleveland, Ohio. In 2009, he earned his Green Belt in Lean Six Sigma through the Center for Innovation in Quality Patient Care at The Johns Hopkins University. David is currently working on his Master of Business Operational Excellence degree through the Fisher School of Business at The Ohio State University.

• Anne Musitano is a Lean Six Sigma Project Leader and staff pharmacist at Akron Children’s Hospital. Anne joined Akron Children’s in 2001 as a staff pharmacist in the Outpatient Pharmacy, after graduating from The Ohio State University with a bachelor’s degree in Pharmacy. In 2004, she then became the supervisor of the pharmacy and returned to Ohio State to earn her PharmD. In October 2008, Anne helped build the program which has now become the Center for Operations Excellence at Akron Children’s Hospital. She completed her Master of Business Operational Excellence degree program through the Fisher School of Business at the Ohio State University in 2010.


accelerating the lean six sigma transformation by engaging physicians

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