Industrial Engineering in an Unusual Healthcare Setting Richard Blackwell

1. Industrial Engineering in an Unusual Healthcare Setting Richard Blackwell Project Director, Process Quality Cermak Health Services November, 2009

2. Summary • Brief history of IE and Quality • Background on Cermak Clinic • Describe the problem: distribution and administration of medications to CCJ detainees • Discuss the approach taken, results to date, and expected outcomes • Outline other IE projects being considered at Cermak • Discuss the potential impact of IE in healthcare and other service industry applications

3. Goals • Discuss and demonstrate use of several IE techniques in an unusual healthcare setting • Value Stream Analysis and process mapping • Six Sigma process improvement (DMAIC) • Quality Management System support of accreditation audits • Suggest possible career directions for IE students

4. Who I Am • Graduated from U of I with MSIE in 1978 • Career trajectory • Manufacturing and distribution applications of OR/MS techniques • Owned my own consulting and software development company • Telecommunications from 1997 to 2009; Project and Product Management; Marketing; Quality • Currently Project Director for Process Improvement at the Cermak Clinic of Cook County Jail After 30+ years in Industry, I still consider myself an IE; everything else is just what I happen to be working on

5. Quality Management Systems - Quick Background • Industrial Engineers (as Scientific Managers) basically invented the Quality discipline – Walter Shewhart, Joseph Juran, W. Edwards Deming • Starting in the 1970s, traditional Quality Control shifted to more comprehensive Systems approaches • Good Manufacturing Practice (GMP) driven by the FDA • International Standards Organization (ISO) Certification • Malcolm Baldridge Award (Motorola the first winner in 1988) • Motorola’s Six Sigma methodology • During the 1990s, an expansion of formal QMS Certification into new areas • Software Engineering Institute’s Capability Maturity Model -> CMMI • ISO “Variants” (TL 9000, QS 9000, AS 9000, …)

6. Our Approach • Starts with Six Sigma as a structured problem-solving approach • Methods (e.g. DMAIC) • Tools: statistical and process/problem analysis • Uses Quality Management System certification as a goal and a club to drive organizational change

7. Cermak Health Services • Part of the Cook County, Illinois Health & Hospitals System • Located in the Cook County Jail • The largest single-site correctional healthcare facility in the US • Provides comprehensive care for ~10,000 detainees • 150,000 sq ft in 129 bed infirmary plus satellite facilities within the jail • Responding to Department of Justice findings from 2008, Cermak is currently upgrading service delivery capacity and methods

8. Industrial Engineering in Healthcare • IEs (as Management Engineers) and other healthcare professionals have often used IE/OR/MS techniques • Process simplification and re-engineering • Process automation • Patient safety • Both IIE and ASQ have divisions that focus on healthcare • Opportunities will expand as healthcare cost containment efforts ramp up

9. Case Study - Medications Administration • 20% of detainees receive medication, with many receiving more than 1 • Patients are dispersed • 129-bed Infirmary for acute care • 3 step-down intermediate care units • General population is in 247 small living units (~50 per unit) in 17 stand-alone Divisions • A court has determined that detainees are to receive all prescribed meds within 24 hours of prescription

10. Complications • Detainees move around • Transferred at short notice, or may be in Court or school at meds admin time • Meds distribution methods vary • Dose by dose administration of TB, HIV, psychotropics, and controlled substances • 7-day self-packs when appropriate • Dispensed from central pharmacy and also from meds rooms in some units

11. The Project • Develop a single, documented process that will be followed for all detainees in the system • Eliminate non-Value Add steps • Shorten the fulfillment cycle to 24 hours or less • Reduce/eliminate missed or incorrect meds • Institute control of drug inventory • Reduce returns • New process is the basis for the implementation of a new campus-wide computer system

12. The Approach – Six Sigma • DMAIC process improvement • Define the problem • Measure the scope of the problem • Analyze process data to understand the root causes of the problem • Improve the system performance • Implement Control system to monitor performance and prevent re-occurrence of the problem

13. Define Stage • Form project team(s) and develop project charter • Map & document current processes • With groups of stakeholders • By direct observation • Develop a measurement plan • Anecdotal data from stakeholders not usually sufficient • Six Sigma requires independent data to ensure objectivity • Measurement allows you to develop and pre-test the metrics employed in the Control plan • Swimlane Map • SIPOC • Value Stream Mapping

14. A Process (“Swimlane”) Map Dept Sub-Process Operation Process Logic

15. Value Stream Analysis • A more elaborate form of process mapping used in Lean • Any step that does not add customer value is a candidate for elimination • Rich vocabulary of symbols for process steps • Moves • Delays • Etc. • Guides the development of a desired “Future State” from the “Current State”

16. Measure Stage • Measurement System Analysis • Descripive Statistics • ANOVA • Variance Reduction • Process Costing • Process Capability • Based on Define stage results, Mean Prescription Flow Time and Delivery Errors per Encounter selected as targets • In order to meet 24-hour requirement, need to know current state • Analysis of Flow Time will support determination of root causes for delays • Delivery Errors cause rework, increase mean flow time, and affect patient safety

17. Unfortunately… • No data is available in current computer systems • Current paperwork inconsistently filled out, results not tabulated • Measurement plan – limited sampling • Observe meds pass and note results • Work backwards through pharmacy records to determine what was prescribed and when • Analyze monthly nursing records for actual delivery

18. Analyze & Improve • DMAIC is not strictly linear; phases often overlap • In this case, some of the required improvements are known • We can use the data analysis to validate required process improvements after we start them • “Surprises” can be leveraged as they occur • Descripive Statistics • “Fishbone” & “5 Whys” • ANOVA • Variance Reduction • Design of Experiments • Process Re-Engineering • FMEA

19. Process Results to Date • Pharmacy capacity is limited by several bottlenecks • Manual entry of Prescriptions • Label printing & manual sort • Staging of meds for delivery to Divisions • Administration in the Divisions contains significant non-Value Added steps • Redundant manual data transcription • “Unnecessary” validation of delivered meds against patient’s medical profile • Impossible with current processes to verify that correct meds have been administered • Improvement approach is to document and implement one standard process

20. An Implementation Plan • Present plan to Senior staff • Form Working Group – CQI, Pharmacy, Nursing, Medical • Draft Context document, review with staff and Software Vendor for accuracy • Combine existing documents and process flows and adapt • Eliminate non-value adding steps • Leverage Software capabilities • Define and implement metrics support elements in Software • Review and revise with Senior staff • Pilot • Review with Dept of Corrections and revise as required • Final approvals • Develop training materials • Train • Monitor & mentor • Process Design • Metrics System Design • Change Management

21. Why Is Implementation So Hard? • Most Process Improvement Efforts Fail • One study shows that 60% of Six Sigma projects end in partial or complete failure • The reasons are not surprising • People don’t like to change • Organizations change all the time, making long-term committed efforts difficult • Management commitment is hard to get and keep • Some projects just don’t make sense

22. Improving the Odds • Techniques exist to improve the odds • Stakeholder & Force Field analysis: understand the management setting and risks before starting a project • Scope Management: • Avoid over-commitment and “creep” by clearly documenting realistic objectives and goals • Avoid projects lasting > 6 months • Change Management: a toolkit for overcoming resistance to change

23. The Control Phase • Implemented using standards-compliant process documentation • Must be supported by senior AND line management • Will face scrutiny by employee unions • Includes key elements of a standard Quality Management System • A performance measurement system • Internal Audit (Self-monitoring) • Management Review; Corrective/Preventive Actions • Verified by an independent accreditation body (NCCHC) • Process Control Charts • Metrics measurement systems • Troubleshooting

24. Continual Management Dynamics • Management Involvement • Management commitment to all aspects of the Quality System • Customer Focus • Management is focused on Customer satisfaction, relationship development and communication • Documented Management System • Documentation is available that provides policy, responsibilities and records in accordance with the Quality System • Internal Audit • Periodically conducted to verify effectiveness of Quality System • Document / communicate audit plan and ensure independence of auditors • Reviewed by Management • Improvement Processes • Monitor, measure and analyze processes for conformity and improvement to products • Corrective/Preventive Actions

25. Other IE Projects • Map & Streamline the sick call process • Map & Streamline the Mental Health care delivery processes • Design meds administration automation processes • Analyze and optimize layout and throughput of a proposed detainee admitting facility

26. Common IE Skills Used • Process analysis • Statistical analysis of process data • Process design, documentation & implementation • Design of management metrics systems • Support of certification/accreditation • Design & implementation of process automation • Cross-disciplinary team leadership

27. Career Ideas for New IEs • Healthcare – it’s exploding • Public Sector – Lord knows they can use us… • Software/Consulting – draw on IE training, & gets you into the game • Project Management – a natural step up from entry-level, and there are never enough PMs • Six Sigma – a natural for IEs; you already know most of this stuff • Lean – IE with a different name

28. Links and Resources • www.punshui.com: my slides and other materials • www.lean.org: lots of ideas and resources re Lean methods and tools • www.asq.org: starting point for Six Sigma and many other directions in Quality • http://www.iienet2.org/SHS/Community/Default.aspx: IIE Society for Health Systems • http://www.asq.org/healthcare-use/why-quality/overview.html: ASQ Healthcare Division • www.pmi.org: professional certification for Project Managers and lots of tools

29. Questions?