Removing Waste and Rework Improving Flow in Presurgery Testing

1. Removing Waste and Rework Improving Flow in Presurgery Testing April 19th, 2011 Vanessa Calderon, Shelby Neel

2. Agenda • What is Presurgery Testing at IMMC? • What is Lean Six Sigma (LSS)? • Project Timeline, Structure, and Roles • Understanding the Current State • Step-By-Step DMAIC Process • Results • Questions?

3. Presurgery Testing Area (PST) Focus 6 Month Process Improvement Project Strong Leadership Support Outpatient Surgery IMMC

4. PST (Pre surgery Testing) • Information Needed for Day of Surgery • History and Physical created within 30 days (Surgeon) • Internist History and Physical (if requested) • Orders for Surgery • EKG • Labs • Diagnostic Tests • Cardiac Records

5. When Information Not Available • Show Stopper • Frustrating for All • Options • Call for Information day of Surgery • Impossible to get info for 0700 start • Delay Surgery • Cancel Surgery

6. What is Lean Six Sigma?

7. Muda (Waste): 7 Wastes • Waste: Anything that adds cost without adding value; The 7 Wastes are: • Transport – moving products that is not actually required to perform the processing • Inventory – all components, work in process, and finished product not being processed • Motion – people or equipment moving or walking more than is required to perform the processing • Waiting – waiting for the next production or process step • Overproduction – production ahead of demand • Over Processing – the creation of unnecessary activity due to poor tool or product design • Defects – the effort involved in inspecting for and fixing defects

8. Value Stream Mapping Current State (Before Improvements): Must determine how things actually are – not how people perceive the process to be! This is achieved through observations and data gathering on activities, time studies, and interviews.

9. Value Stream Mapping Issues (Areas of opportunity) Identified using “Kaizen Bursts”

10. Value Stream Mapping Wastes and Rework Identified (Transportation, Walking, Rework, Non-Value Adding Activities such as phone calls)

11. Value Stream Mapping Process Cycle Efficiency Determined (VA vs. NVA Time) – 40%

12. DMAIC Project Framework

13. Project Background – Timeline (Ramp-up)

14. Project Background – Timeline (DMAIC Project)

15. Project Structure and Roles Steering Committee • Steering Committee • Steers the project and makes decisions about goals and milestones • Makes strategic/directional and financial related decisions • Active involvement with roadblocks and overall progress • Recommend same people over life of the project (1-5% time spend) Core Team • Core team • Manages and structures the project, develops and executes overall project plan • Communicates project deliverables and status to Steering Committee • Consists of key clinical process owners 1)MD’s 2) RN’s and 3) One project lead/manager that stays the same over the course of the project for continuity (50% - 100% time spend) Team Leaders Staff / SME’s • Team Leaders • Dedicated Process leaders that organize, develop, and leads problem definitions, metrics, root cause analyses, solution development and testing, and final implementations • Delivers information and prepares recommendations • SME, Subject Matter Experts (e.g. ORSOS expert) • Supply input, based on experience and expertise on a specific part of the project. • The required experts can change per phase. (5-10% time spend)

16. Project Structure and Roles Amy Bethel, Eric Lothe, Kathie Nessa, Dennis McInerney, Dr. Mark Purtle, Dr. Steve Stephenson, Dr David Stubbs, Dr. Mark Sundet Steering Committee • PhysiciansTeam Leaders (RN’s, Techs, MD’s) • Dr. Stubbs (Surgeon) Margie Higdon – IMMC OR (Surgery) • Dr. Sundet (Anesth.) Leigh Ann Wachter /Chanel Hubby-CSP Douglas (Doug) Reed – ILH OR (All) • Shelby Neel – IMMC PST • Project Leaders / Process Improvement: Dennis McInerney/ (Industrial Engineers) Vanessa Calderon Core Team Margie H. Doug R. Shelby Neel Leigh Ann W./ Chanel Hubby Team Leaders Staff and SME’s

17. Understanding the Issues of the Current State in PST What were we dealing with?

18. Our Process • Call the day before surgery requesting missing information for patients. • H & P • Orders • Labs • EKG • Cardiac Information

19. Issues Addressed • Issues with Faxes • Faxes deemed lost • Sensitive Patient Info • “Batching” or faxes means waiting needlessly for information or calling for something we already have! • DCR Tracker • Electronically converts fax to PDF-like document for viewing on computer screen rather than printing paper copy immediately • Reduced but did not eliminate these issues (still batching and faxes claimed to be lost)

20. We Understand • Physician Offices are Busy • Our calls disrupt their work flow • Chart information may not be available the day surgery scheduled.

21. Many Surgeons (141) Many Offices (>100) Information comes to us randomly Required call before send information Surgeons

22. Problem with Current Work Process • Information Not Always Available Day of Surgery • Assessments Not Completed • Labor Intensive for BOTH of us.

23. Labor Intensive • 3 Nurses Dedicated to PST Process • Each Nurse Spends about 4 hours a day calling for information • ~ 60 hours/week • 1.5 FTE dedicated to calling for info.

24. Financially • Roughly $100,000 per year spent on nursing salary calling for information. • Proportional amounts of financial strain on physician’s offices as well

25. Ideally • At time schedule surgery • Orders • H & P • Labs • EKG (if applicable) • All pertinent chart information

26. Two Main Issues • Not getting required chart Information by day of surgery • Pre-Assessments not getting completed (Requiring them to be done on the Day of Surgery which takes extra time and is a patient dissatisfier)

27. Using the DMAIC Framework • Define • Measure • Analyze • Improve • Control

28. Define

29. Measure (Call Tracker) Populates with special instructions specific to the Physician’s Case

30. Data (Measure) Although 83% of information is received day before surgery, 17 out of 100 charts are still missing crucial information.

31. Missing H & P by Specialty (Measure) Day prior to surgery missing 33% to 50% H & P by specialty. Problem with the process.

32. Completed Assessments (Measure) Nurses spending a lot of time calling for missing information. Unable to get assessments completed.

33. Calls to Physician’s Office (Measure) Based on 3,107 charts reviewed, there was 1,140 calls to offices.

34. Missing Orders Day Prior to Surgery(Measure) Day prior to surgery missing 23% of orders for surgery.

35. Missing History and Physicals (Measure) Day prior to surgery missing 35% of H & P’s.

36. Time to Receive Faxes (Measure) From time nurse starts processing a chart in pre surgery area until they receive all information for surgery, is average of 1 hour 42 minutes.

37. Assessment Length (Measure) • Used data from Carecast timestamps to compare Day of Surgery Assessment reviews with and without pre-assessments completed • Often found it didn’t save time overall, but did save a few minutes (5-10 min.) on the day of surgery. • If we can eliminate the time to pre-assess, the overall time between pre-assessment and day of surgery will be reduced…Online Assessments!

38. Surgery (Measure) • Average Surgery scheduled at IMMC is 21 days prior to actual surgery date. • This represents our lead time to collect the proper documentation and patient assessment.

39. Analyze • Value Stream Map / Process Map • Data • Spaghetti Diagrams • Mapped Work Flow • Root Cause Analysis • 5 Y’s • Problem Identification • Issue Log’s

40. Analyze (Vision) • Getting Chart Information • How ????? • Online Assessment • How????? • Leadership Support • Tell Our Story

41. Analyze (Potential Solutions) • Meeting with Offices • Lackluster Response • IT Solutions • Roadblocks • Work Smarter not Harder • Online Assessment Company • Denied

42. Analyze • What direction to go?? • Became Detectives • Started Testing Solutions

43. Improve – Test of Change • Process Flow Map • Remove waste (rework) by eliminating repeat calls to same location. • Scheduling asks for missing documents while confirming surgery

44. Get Organized: What is 5S? Based on five Japanese words that begin with ‘S’, the 5S Philosophy focuses on effective work place organization and standardized work procedures. • Sort – eliminate items not used in the process • Set In Order - organize, identify and arrange everything in a work area • Shine - regular cleaning and maintenance • Standardize - make it easy to maintain - simplify and standardize • Sustain -maintaining what has been accomplished

45. Before/After Pictures (Drawers) BEFORE AFTER

46. Before/After Pictures (Binders) BEFORE AFTER

47. Before/After Pictures (Standard Work) NONE BEFORE AFTER

48. Implementation • Communication Sheet • Front of Chart • See what has been done at a glance • Also helped Pre-Op and OR

49. Test of Selected EMR Access • Allscripts • Selected Access (Only see certain parts of patient record) • Learned of opportunity through OB

50. Implementation • Leadership Support • Meeting with The Iowa Clinic (TIC) (Spearheaded by Dr. Stubbs) • 40% Surgeries • Goal • Have selected access to their EMR • Orders (60 days) • H & P’s (60 days) • Labs and Diagnostic Tests (1 year)