Lean 6-Sigma Program

Gretchen Deel, M.D.

(Project Greenbelt)

CALIFORNIA DEPARTMENT OF CORRECTIONS

AND REHABILITATION

S. Roberts, MD

M. Farrell, SRN III

(Project Champions)

Mary Ann Glynn, CEO, RJD

(Executive Sponsor)

Project Team: Gretchen Deel, MD – Green Belt Candidate

Chris Carlson – Master Black Belt Coach

Tera TranOn – Black Belt Coach

Mary Ann Glynn, CEO – Executive Sponsor

Steve Roberts, MD – Project Champion

Mia Farrell, SRN III – Project Champion

Ryan Barenchi – Team Member

Lia Stephenson, SirPatrick Paragas – Telemed RNs

Beth Kadani – Telemed Scheduling, Local

Lean 6-Sigma Program

Lean Six Sigma Project: Improving Compliance of Urgent Recommendations from Telemed Specialists

RJ Donovan Telemed Program

Largest volume of Telemed Specialist appointments

Telemed reduces cost and improves safety

Problem Statement/Metrics

Primary Metric: Improve compliance of Urgent Recommendations made by TelemedSpecialist

Urgent = 14 days

Secondary Metric: Improve quality of medical care, reduce cost of medical care

Lean 6-Sigma Program

Upper Spec Limit = 336 hours (14 days) to meet compliance Current Average = 723 hours (30 days) Current maximum 2,800 hours (117 days) % within spec limit = 32% 68% of time = Not meeting goal

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Baseline Capability

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Initial Process Map

insert process map

42 steps5 VA steps37 NVA steps2 rework loops

40 Steps2 VA Steps38 NVA Steps2 Rework Loops

FISHBONE DIAGRAM

TIME VALUE CHART

FMEA

PARETO CHART

SECONDARY PARETO CHART

MULTI-VARI ANALYSIS

HYPOTHESIS TESTING

MOOD’S MEDIAN TEST

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Analysis Tools

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Key Analytical Findings

FMEA – Potential Critical X’s

Pareto Chart – Critical X’s Failure of RN to

Identify a Recommendation as Urgent

Variable Availability of Specialist note for the PCP

Failure to identify urgent recommendations primarily associated with lack of training/experience

Access to Specialist note did not vary between 16 different PCP’s

Varying the Specialist did not significantly influence the timing

Lean 6-Sigma Program

Key Analytical Findings 2

Root Cause of Critical X’s: 5 Why’s

Failure to identify Urgent accounted for 47% of defects

Follow-up wasn't done in 3d causing delay

Variability in RN ordering Urgent PCP follow-up

different experience levels of RNs

Urgent Rec not recognized as different from Routine

RN's that were new to the process did not know Urgent Recs are different

Failure to consistently alert Urgent Recommendations

No standardized training

Urgent Recommendations may occur during a routine visit

Variability in training

Variability in level of care needed with each visit

No standardized process re Urgent Telemed recommendations

No standardized training re Routine v Urgent Recommendations

Defect was not identified in the past

The process was not evaluated as each change happened

The initial workflow process had to change to accommodate RJD large volume

Why?

Why?

Why?

Why?

Failure to access specialist rec accounted for 23% of defects

The specialist's note is difficult to access

It is in MedWeb, retrieved by HIM

HIM has one of the few licenses given out to the facility

When a note is missed there is no notification that it has not been retrieved

Only a few licenses for MedWeb are given out by HQ

HIM pulls the note from all the notes written that day

Cost constraint/HIPAA regulations?

HIM chose not to use the email notification method

A Specialist's note that is not accessible by the PCP causes delay

HIM thought the email notification method would be inefficient

If there is not a note in the chart, the I/P 3d FU visit gets rescheduled

RJD Telemed volume is much larger than other institutions

Specialist notes sometimes are not in the chart in time for the PCP to read it on the 3 day FU

If a note is missed or not put in chart, there is no detection process

One person is responsible for retrieving the note, with no alerts for missed notes

Not Identified as Urgent Note Access VariabilitySPECIFICPROBLEM

DETECTIONFAILURE

SYSTEMIC FAILURE

Failure to Identify/Alert Recommendation as Urgent Standardize process for Telemed RN Training

• RN• PCP

Variable Availability of Information Standardize process Training

• PCP• RN• Telemed Scheduler• HIM• Specialist

Process changes• Email notification – failed/volume• PCP access to MedWeb – requires individual license/add steps• Minimize NVA steps to free up time/improve accuracy

Lean 6-Sigma Program

Improvement Targets based on Root Causes

Standard Work for each process/Visual aid reminder

PCP

Telemed RN

Telemed Scheduler

Urgent Alert Stamp

Standardized training

Educated employees on 5S organization aided by moving centrally

Distance decrease: TM Scheduler moved to HUB near TM RN

eRFS

Decrease NVA steps

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Improvement Implementation

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New Process Map

insert new process map

4 NVA steps removedPaper document removedRework steps simplified

Initial Process Capability: 32%

Final Process Capability: 88%, 87% and 93% for past 3 months

Lean 6-Sigma Program

New Capability Analysis

old capability

Controls to be Implemented

Identification of Recommendation as Urgent

Availability of Specialist’s note in chart

Evaluate 10 Charts each month x 6 months, then 20 charts every 6 months

Update Process Capability

Update Process Control

Update FMEA as needed

Re-evaluate process for improvements

Lean 6-Sigma Program

Control Plan

Hard Costs

No “increased revenue”

Telemed Professional/Technical = $35,000; this is < 1 emergent sendout

Cost savings – average of 10 incidences of delay

$2,198 x 4,000 pts/year x .68 failures = $5,978,560

$2,198 x 4,000 pts/year x .13 failures = $1,142,960

Savings = $ 4,835,600 per year

Emergent or offsite visit v onsite

Custody Officer time travelling v inhouse

Transportation time to & from hospital

Hospitalization time – if extended for emergency

Telemed RN/Scheduler/Specialist time

Main acute sources of cost – Cardiac procedure, Sepsis

Specialties with the highest difference in costs

Lean 6-Sigma Program

Financial Benefits

Most Expensive Delays by Specialty

cardiology general surgery ortho

oncology urology other

Improved healthcare for patients

Increased customer satisfaction

Fewer grievances/appeals/lawsuits

Improve morale for employees

Less employee turnover

Less tax burden

Lean 6-Sigma Program

Additional Benefits/Soft Cost

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A3

Name: Gretchen Deel, MD

Phone: (619)661-8634

Email: Margaret.Deel@CDCR.ca.gov

Lean 6-Sigma Program

Green Belt Contact Information