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Flow Chart

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by

Mike Rizzo

on 25 June 2013

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Transcript of Flow Chart

"There are no big problems, just a lot of little problems"
- Henry Ford
See what it is
See what it was
Our National problem

Medicine Beyond 2012: A Choice

Preserve Career Satisfaction

Increase Perceived Value
and
Decrease Cost
AND

Inflection

Adapt

No change

Health care reform,
Double threat
Economic Meltdown,
Unemployment
13%



5%


12%






64%

Choice

US Revenue and Expenditures
Kaiser and Health Care Reform
2008 2013 2015
Cutting Cost First:
- Reduce Staffing
- Reduce Compensation
- Still maintain Quality & Service (How?)
- Work Faster
- Work Longer
NO
Improve Efficiency
- Change Work flows
- Eliminate Waste
- Lean
i.e. Process Improvement
(and Improve Attendance)
Process Improvement
Leadership Cohort
June 2013

Patient's problem:
Your problem:
Three Flavors of Performance Improvement:
1. 2. 3.
Prayerful Penitential Process Improvement
(Do Good.) (Are we righteous?) (Think Different.)
Standard
Process
Map
5 S
Value Stream
Mapping
Waste
Variation
Process
Improvement
Process Improvement analyzes - and then changes - processes to:
Get better
Gain efficiency
Be more cost effective
AND
Be safer
Decrease aggravation
Improve access / decrease waits
Target area for improvement


Define current process


Identify Improvement
Opportunities


Test


Implement Improved Process
Identify problem area
Prioritize projects
Set improvement goals
Map current process
Engage with customers
Engage team and team charter
Identify waste and inefficiency
Find improvement
MEASURE
Set
SMART
goal
Implement changes
Plan for sustainability
Spread improvement
Act
Plan
Do
Study
Keys to Success:
Team Planning
Team empowered to improve their work
Process Improvement: simple and intuitive steps
Understand work flow (
Process Map
)
Find problem(s) (
Problem Statement
)
Set goal (
SMART Goal
)
Set
Measure
Test changes (and collect data/measure)
Make improved process your new work flow
SMART = Specific, Measurable, Achievable, Reasonable, Timebound
Process Improvement: Three Questions
1. What are we trying to accomplish?
2. How will we know that a change is an improvement?
3. What change can we make that will result in an improvement?
Step 2:
PDSA
Small tests of change
Act
Do
Plan
Study
- Systems too complex to
"intuit" a solution
- Stakes too high in medicine
to rework whole system on a guess
Enough Mumbo Jumbo:
How do you find problems
(and answers)?
Try a value Stream Map.
Value Stream Map
- A process map with added time dimension
- Purpose:
- Show duration of each process step and waits
- Create from perspective of
customer

- Find 'value added' and 'non-value added'
-Focus improvement areas
Value Added:




Non Value Added:
Provide care to patient
Meet patient expectations
Satisfy legal requirements *
Ensure safety
Waiting
Duplicating information, requests, calls,
tests
Patient movement between sites
Multiple triage steps / approval steps
Type 1 - required waste
Type 2 - worthless waste
Exercise: Group Value Stream Map
Medicine is often
1-5%
efficient !
CT Scanning:

Triage Schedule Lab Pharmacy Scan
5 min 3 min 20 min 35 min 5 min

Wait Wait Wait Wait Wait

0 24h 72h 5d 10d

Emergency Department (2008)

Triage Vitals X-ray Lab Casting/Suture
5 min 3 min 20 min 15 min 25 min

Wait Wait Wait Wait Wait

0 2h 4h 6h

Pediatric specialty clinic visit

Triage Schedule Lab X-ray Office Visit
5 min 3 min 20 min 35 min 75 min

Wait Wait Wait Wait Wait

0 24h 72h 5d 10d

v. Walk In CT


Book>Register>Lab>Scan

CT Scanning: Traditional

Triage Schedule Lab Pharmacy Scan
5 min 3 min 20 min 35 min 5 min

Wait Wait Wait Wait Wait

0 24h 72h 5d 10d

Value Streams.
Slow or Fast.
We all have them.
To be or not to be
How to know
How to do
To do
See what it is
See what it was
How does the process work now?
I think. I now know. I wish.
Is there
a
process?
Traditional Management blames people.

Process Improvement assesses process to improve a system.
Standard Process Map:
"If I had to reduce my message for
management to just a few words,
I'd say it all had to do with reducing
variation."

- W. Edwards Deming
Variation is . . .
EVIL
Process #1 Process #2
Roy (Doc) Halladay:

- 46 complete games
since 2002

- 2003: 200 strikeouts,
fewer walks than starts

- Identical pitching
motion. Every pitch.
Not top-down 'traditional' management fix.
But,
Team of those engaged in the process.
Team knows what is
broken, slow, aggravating,
dangerous, wasteful, dirty,
disorganized, inefficient,
costly, or hurtful.
Team can figure out how
to fix it and keep it fixed.
Process improvement is more management style than a 'technique'.
Everyone has two jobs:
1. Care for patients
2. Improve their job
Three Questions of Process Improvement:
Question 1: What are we trying to accomplish?
A good
problem statement
answers:
What is wrong?
When does it occur?
Where does it occur?
How large is the problem?
Who is affected and how often?
Problem statement:
56% of our out-patient clinic patients are not seen by physician within 10 minutes of scheduled appointment.

Problem statement:
Between 10 a.m. and 2 p.m. patients wait an average of 42 minutes for out-patient x-ray.
S.M.A.R.T Goal:
90% of our out-patient clinic patients will be seen by physician within 10 minutes of scheduled appointment by August 1, 2013.
Three Questions of Process Improvement:
Question 2: How will we know that a change is an improvement?
Data over time drives process improvement, not
aggregated tabulated (judgemental) data.
Outcome Measures
Process Measures
Balancing Measures
Measure for Process Improvement:
Simple, precise measure reflecting change effort.
Measure to learn, not to judge.
Good enough measure and data collection. Goal is not perfection.
Collect from one site, a few days, one staff, one MD
Don't wait for a crystal report from HealthConnect !
Simple
Data
Run
Chart
Three Questions of Process Improvement:
Question 3: What change can we make that will result in an improvement?
"All improvement will require change, but not all change will result in improvement"
Brainstorm:
Where to Start?
5S is not a one time event
Nothing will last without 5S first
5S:
Sort
Self
Discipline
Standardize
Sweep
Simplify
Perceived Value
Cost
- Quality



- Safety



- Service
Sholdice Hospital
Cystic Fibrosis
Virginia Mason
Airline Industry
Time out Checklist
CLABSI, VAP
U of Michigan
4 Habits
- Standardize Process

- Improve process

- Adhere rigorously
5S (accidentally)
Ideal Room Inventory
Grid cassette holder
Sand bags
Positioning pads
Orthopedic ball marker
IV pole
Stool
Pillow
Tape
Radiation cones
Cleaning Supplies
Ideal: v. Where's the %*!@# holder?
So, 5S for medicine is:
Sort what is needed from the unneeded
Obtain equipment/supplies for each location
Label location for equipment/supply; label equipment for location
Standardize
supplies used
Make it a daily and hourly habit
Decrease wasted motion, improve throughput, decrease patient waits.
Try it: Cross off numbers from 1 to 49 in order.
How hard can that be?
5S: Which numbers (1-30) are missing?
5S: Which numbers (1-30) are missing?
Question #1: ( Re: Quality, Safety, Efficiency, Cost)





Are we the best?
Not, are we better than we used to be (we are),
Not, are we better than our local competitors today (we are),
But:
Should we be? Can we be?
Consequences - for patients and us - of not being the best.
Starting Points for Process Improvement
Value Stream Map (Process Map)
5 S
Waste Reduction
Process Improvement Lessons
No improvement happens without a goal
Every process is perfectly designed to produce the result it obtains
No improvement happens without a goal, but not all change leads to improvment
Collaboration is key to sustain change
Commitment of leadership is essential
Thanks.

And Questions?
Plan
Do
Act
Study
Process Improvement: a Model
Process Map:
Variation
Measurement
5 S
Whether you think you can, or think you can't -
you're right.
--

The ones who are crazy enough to think they
can change the world, are the ones who do.
-- Steve Jobs
3 Questions
Government expenditures
as Percent of Revenue:
Choices we make:
Full transcript