Lean in Healthcare Systems - ASQ Orange...
Transcript of Lean in Healthcare Systems - ASQ Orange...
Lean in Healthcare
Bohdan „Bo” W. Oppenheim, PhDProfessor of Systems Engineering, LMU
American Society for Quality Orange Empire Section 0701
Presentation
1. Some statistics and problems in U.S. Healthcare2. Healthcare as a System, and Systems Thinking3. Lean is a Critical Element of Healthcare4. LMU-KP Partnership5. Lean improvements in KP Medical labs 6. Summary
• $8,508 per capita (UK: $3,406)
• Millions still without medical insurance
• Medicines unaffordable to a hundred million people
• Over 30% of U.S. adults skip a recommended test or treatment because of cost
• U.S. ranked #70 in wellness (mostly due to obesity)
• U.S. ranked last among 11 countries in preventable deaths
The Present Imperfect State
Bohdan W. Oppenheim, [email protected] 7
Many reasons for high cost and poor outcomes…
• Historically wrong financial incentives (pay per service)• Lack of universal care, highly fragmented system• Employer-based system• Weak systemic push-back on costs• Crazy reimbursement/insurance system
2. Healthcare as a System and Systems Thinking
SuperSyste
m 1
SuperSystem
3
SuperSystem
2
SuperSystem
4
Complex System 1
Complex System 2
U.S. Healthcare = Dynamic Hyper System
Help from Systems
Engineering
Healthcare Stakeholders• Patients (300,000,000+ in U.S.)• Medical professionals• Medical facilities, hospitals,
clinics, labs• Medical Equipment• Pharmaceuticals• Researchers and academia• Insurances• Employers• Federal & State Governments • Military and Veterans
Administration• Fire Departments and
Ambulances• and more
Powerful Solution
Bohdan W. Oppenheim, [email protected]
6
Powerful Studies Using Huge Databases of Patients’ Records
© 2014 Gary Robert Smith, Understanding Disease Through Systems Thinking, INCOSE IS 2014.
Number of potential medical records: • Kaiser Permanente: 10,000,000• U.S. 300,000,000• World 7,000,000,000
Huge data „mining” now permits powerful studies of simultaneous effects of numerous factors and complex interations. We are no longer constrained to simplistic clinical studies that filter out confounding and interaction effects. This yields rich medical knowledge and potent treatments.
Bohdan W. Oppenheim, [email protected]
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3. Lean is a Critical Element of Healthcare
Lean does not tell MDs how to treat patients – it frees the
MDs to do it more and better
Desired Characteristics of Healthcare
• Affordable & Accessible• Safe • Effective• Patient centered• Timely• Efficient• Inclusive of Latest Science• Well integrated
Bohdan W. Oppenheim, [email protected] 6
Streamlining operations and removing waste using LeanAdded Value from Systems Engineering in Healthcare
Lean does not tell MDs how to treat patients – it frees the
MDs to do it more and better
Lean Principles
Bohdan W. Oppenheim, [email protected]
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Ohno’s Eight Types of Waste
Type of waste Brief Description Hospitals examples Defects Time spent doing something
incorrectly, inspecting for errors, or fixing errors
Surgical case cart missing an item; wrong medicine or wrong dose administrated to patient
Overproduction Doing more than what is needed by the customer or doing it sooner than needed
Doing unnecessary diagnostic procedures
Transportation Unnecessary movement of the “product” (patients, specimens, materials) in a system
Poor layout, such as the lab being located a long distance from ED
Waiting Waiting for the next event to occur or the next work activity
Employees waiting because workloads are not level; patients waiting for an appointment
Marc Graban, "Lean Hospitals, Improving Quality, Patient Safety, and Employee Engagement”, Second edition, (CRC Press, 2012) 11
Ohno’s Eight Types of Waste
Inventory Excess inventory cost through financial costs, storage and movement costs, spoilage, wastage
Expired supplies that must be disposed of, such as out-of-date medications
Motion Unnecessary movement by employees in the system
Lab employees walking miles per day due to poor layout
Over processing
Doing work that is not valued by the customer or caused by definitions of quality that are not aligned with patients needs
Time/date stamps put onto forms, but the data are never used
Human potential
Waste and loss due to not engaging employees, listening to their ideas, or supporting their careers
Employees get burned out and quit giving suggestions for improvement
Marc Graban, "Lean Hospitals, Improving Quality, Patient Safety, and Employee Engagement”, Second edition, (CRC Press, 2012) 12
Waiting (one of the eight wastes of lean healthcare) has a huge impact on patient Outcomes and Costs
Faster treatment means quicker, more complete recovery.
John Toussaint, MD and Roger A. Gerard, PhD with Emily Adam, “On the Mend, Revolutionizing Healthcare to Save Lives and Transform the Industry”.
13
Example: Lean improved STEMI Value Stream by 80%(Heart attack caused by a prolonged period of blocked
blood supply)
John Toussaint, MD and Roger A. Gerard, PhD with Emily Adam, “On the Mend, Revolutionizing Healthcare to Save Lives and Transform the Industry”14
Visit Clinic
Phone call
Phone call
LEGEND
2.1
4.4
Discha
rge
Discha
rge
3.1
14.0
1.6
2.2
9.7
19.1
20.7
31.2
Phone call
- No shows – 2%
- On-time starts – 37%
- Document delays – 12%
Reception
Obtain Demographics
“mini-reg” & Send packet Reception
Call patient to schedule
- Volumes by service – 13.0%
- Lead-time by service - varies
Reception
Input Med HistoryHot
Jefferson Healthcare Clinic – Future State Focus (2008)OVERALL CLINIC DATA
- Cost per visit - $125.39
- Avg. Pts per hour - 1.83
- Available hours per day – 67
PATIENT
Reception
Check-in patient for
visitRN
Room & perform
vitals, etc.
- On-time starts – 37%
- Time by diagnosis – Chart D
- Volume by hour – Chart E
- Schedule on 1st call – 0% - # of Pts on panel - 5998
- Days out for first 3rd visit 2.00
- Days out by provider- see chart C
2.3
4.8 walk or return
Walk tohospital
Hospital Registration
Register for Ancillary Services
- Referral volume – 14.5 %
MD, PA
See patient
HOSPTIALAncillary Services
PATIENT DATA
- Volumes - 131 visit/day
- Market share - Hospital 46.7%
- Cancel by reason - see chart A
- Payor mix – commercial 38%
- Satisfaction – overall 74.4
- Volume by Diagnosis – See chart BWait for ex prov
to return info
Wait for pt to
return packet
Reception
Receive call & Send
registration packet
Reception
RequestMed
History records
Reception
Receive Med History
& Call to Schedule Reception
InputMed History
Document delays – 2%- Schedule on 1st call – 0% - # of Pts on panel – 5997
- Days out for first 3rd visit – 3.75
- Days out by provider - See C
EXTERNALPROVIDERS
Disc
harg
e
Reception
Pre-reg, Schedule, & Send packet
Reception
Input Med History
following Check-in
- Document delays – 30%- Schedule on 1st call – 100%
- # of Pts on panel 5886
- Days out for new visit - 15.01
- Days out by provider – See Chart C
Days out for first 3rd visit – 1.16
= JMPG Scheduling
= OPC Scheduling
= PTFP Scheduling
= Clinic flow (all sites)
= Hospital Services
= Patient
Reg PktV1
Reg PktV2
Reg PktV2
Enterprise
Enterprise
Enterprise
Enterprise
Enterprise
ROSV1
ROSV1
ROSV2
MedHistory
Enterprise EMRInterfaceMedlist
EMR Orders
Scripts
Educ.
Routing Slips
EXTERNALPHARMACIES
Referral Coordinator
Check-outpatient
MediTechInterface
Scripts
EMR Referrals
Radfilm
MediTechEMR
EMR
EMR
Salmon reminder (PTFP)
= Patient on schedule
- Blocked Hours – 67/day
- Contact Hours 59/day
- Utilization 88%
C/T
L/T
Develop standard scheduling template
by 4-1-08
Develop clinic service
standards by 12-31-07
Develop standard registration packet
by 12-31-07
Develop pre-order & future lab
capabilities in EMR by 7-1-08
Develop standards for scheduling &
reception by 4-7-08
Develop process for capturing Hx
pre-visit by 7-1-08
Implement daily huddle by 11-1-08
Develop standard room
by 4-1-08
Develop post-visit standard work by (TBD)
Align to care teams in pods
by (TBD)
Standardize visit documentation
by (TBD)
Hire/train MA resources
Improve staff satisfaction
by (TBD)
Improve Pt satisfaction
by (TBD)
Establish Pt focus group
by 4-1-08
Address safety measures &
gaps by 10-31-08
Eliminate need to re-register in
hospital
Source: Jefferson Healthcare, Port Townsend, WA
EdNET 2012
Example of Lean VSM – Jefferson Healthcare Clinic (2008)
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Less than 20% Value AddedSource: University of Iowa Hospitals and Clinics
Write O
rders
Clerk w
rites req
Req Tubed
Assescioned
Print Labels
Sorting
Checking
Travel
Checks B
ook
To R
oom
Get S
upplies
Wait
Check ID
Sam
ples
Label
To B
asket
Runners
Test
Post
Read
Wait
Treat
5 20 10 5 5 5 5 10 5 5 5 10 5 5 5 10 10 10 15 5 20 5 180
Example: 80% or more of the time spent in a healthcare processes is waste
EdNET 2012
A real medical example - a test-and-treat cycleMost of the patient time is spent waiting, moving, etc.
16
Example: Lean Optimization of Outpatient Visits(Removed wasted time, gave more time to MDs and Nurses)
Source: Jefferson HealthcareEdNET 201217
Example: 6S - A simple “Lean tool”
• Sort• Safe• Straighten• Scrub• Standardize• Sustain
Before
After
Source: University of Michigan Health System, Ann Arbor, MI
EdNET 201118
Example: 6S in Clinic Rooms
Source: Jefferson HealthcareEdNET 201219
Example: Study of Bottlenecks
GP Referral AppointmentMade
OutpatientVisit
Add toWaiting ListSurgeryFollow-up
Discharge
100/day 100/day 50/day
150/day15/day60/day
140/dayBottleneck!
EdNET 2012 20
So, Lean has a big role in Healthcare
• Lean is very different from traditional “COST CUTTING” approaches
• Lean hospitals do not…
– improve quality by asking people to be more careful
– improve productivity by asking people to run around faster
• Lean removes waste, to give more time and resources to MDs, patients, nurses
4. LMU-Kaiser Permanente Partnership in Lean
Healthcare
LMU-KP Partnership in Lean Healthcare
• Initiated by LMU in 2012 as a partnership of the best…– Selected KP because of top national rankings – LMU is a national leader in Lean
• Created an advanced 3-course graduate Certificate in Lean Healthcare
• First focus on streamlining huge medical labs– 10 KP students in 1st cohort, all managers of KP labs– Remarkable results, high praise from students and KP managers– Second student cohort finishing soon
• LMU expanding to other medical facilities in SC• More partnership projects planned with KP in Healthcare Systems
Thinking, Big Data
Graduate Certificate in Healthcare
Courses1. Lean Healthcare (teach Lean basics in healthcare context), based
on MIT EdNet work)
2. Project (learn by doing). 10 students, all lab managers streamline their labs with intensive on-site mentoring by Bo Oppenheim ($15 million saved, throughput time saved 30% -70%, higher quality of tests, numerous wastes eliminated…High praise from KP top management
3. Advanced Lean Management of Healthcare, (learn by teaching) Students develop Lean Enablers, (i.e., best practices inspired by Lean) for managing their and other medical labs. LMU has significant experience in development of Lean Enablers for SE and Program Management.
5. Six Examples of Lean Improvements
in KP Medical Labs Credits: • Onie Bueno, Manager, Bacteriology Lab• Leland Chan, Specimen Processing Department (SPD)• LaRonda S. Frazier, MS, Director of Microbiology Lab• Jocelyn Javier, Glenda Lumampao, Carlo Punu, Medical Centers• Mike M. Moradian, PhD, Director of Genetics Lab• Chiemi Tabata and Vincent Dizon, Managers, Automated Chemistry Lab• Michael Tiffert, Section Manager Cytogenetics and FISH Lab
Most Samples (blood, urine, biopsy…) tested in regional lab in Sherman Oaks
5
2802
9970
1972
101
1292
7103
3453
2157
923
2443
3806
441 3710 0
786220
484 430
2096
3999
2107
0
5:00PM
6:00PM
7:00PM
8:00PM
9:00PM
10:00PM
11:00PM
12:00AM
1:00AM
2:00AM
3:00AM
4:00AM
5:00AM
6:00AM
7:00AM
8:00AM
9:00AM
10:00AM
11:00AM
12:00PM
1:00PM
2:00PM
3:00PM
4:00PM
24 HOUR SPECIMEN ARRIVAL PROFILE (12/09/13 TO 12/10/13)
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Specimen Processing Department (SPD)
LabotixAutomation
SPD DistributionTable
Couriers fromMedical Centers/ MOBs
SpecimenProcessingDepartment
(SPD)
AutomatedChemistry/
Endocrinology
Special Chemistry Immunology
Cytology8-12 hrs
Virology4-48 hrs
Blood Donor12 hrs
FrozenSpecimens
8-16 hrs
Outside Lab8-24 hrs
Genetics 4-8 hrs
Allergy Lab8-16 hrs
Bacteriology10 mins-4 hrs
B&T Lab4-8 hrs
Manual Processing
Automated Processing
IFOBT1-3 days
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Manual Sorting in SPD
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Sorted Samples from Evening Delivery
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Lean Improvements in SPD
• Eliminate errors• Reduce batching and inventory• More JIT processing• Streamline operations• Eliminate waiting
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Medical Center
Specimens
Couriers
MOBSpecimens
Specimen Processing Department
(SPD)
STATTest?
Yes
No
Yellow Bag
STAT Alert?
Yes
No
Specimen received, processed & logged
in for Testing Department
Manually locate or Labotix Rejection
Manually deliver specimens to
Testing Department
2-4 Hours
Routine Test?Yes
No
Labotix Automation
Labotix throughput is 1,500 specimens/
hour
Manual Process
Manual ProcessAutomated Process
ImmunologyAnalyzer
Automated Chemistry/
EndocrinologyAnalyzer
Special ChemistryAnalyzer60
minsManual Process
BactiTest?
Histology Test?
Cytology Test?
Genetics Test?
B&T/Allergy Lab
Test?
No Yes
All BacteriologySamples
Deliver to BacteriologyAutomation
No
No
No
Yes
Regional Couriers delivers directly to Histology Dept. Specimens
do not stop at SPD.
SPD Lab Staff receives Non-Gyn specimens and sends to
Cytology. SPD Lab Staff sends PAP specimens to Cytology
SPD sorts, place onTransfer Lists
SPD Lab Staff sends Outer Tub to
Genetics Lab via Regional Courier
Yes
Yes
SPD sorts, place onTransfer Lists
SPD Lab Staff sends Outer Tub to B&T or Allergy Lab via
Regional Courier
Archiver
Lean Improvements in SPD
Current Process
Non-value added
Required / Non-value added
Value added
Legend
32
Lean Improvements in SPD
SPD Before and After
Operational Impacts Current State Future State
Throughput (# specimens) 2800 4,000
Quality Medium-High High
Frustration to Staff High Low-Medium
Frustration to MD, Members/Customer High Low-Medium
.
33
34© LMU SELP 695, Dr. Oppenheim
Pos
t-A
naly
tica
l
Analyze results on instrument
software
Analyze results on instrument
softwareExport raw data to an excel file
Export raw data to an excel file
Copy paste Ct values to excel
sheets and graphs to a word
document
Copy paste Ct values to excel
sheets and graphs to a word
document
Prepare a WSD and WSL
NotePad file
Prepare a WSD and WSL
NotePad fileFormat
correct?Format
correct?
Transfer data to the excel with
raw data
Transfer data to the excel with
raw data
Use macro to format and then transfer WSD & WL reports into excel
Use macro to format and then transfer WSD & WL reports into excel
Manually enter RNA information
in the excel sheet
Manually enter RNA information
in the excel sheet
Prepare patient last run history list and confirm the history by checking LMS
Prepare patient last run history list and confirm the history by checking LMS
Enter prior history for
patients with changing result
trends
Enter prior history for
patients with changing result
trends
Enter the results into word
template one by one
Enter the results into word
template one by one
No
Yes
Copy and paste the results to
LMS report and verify correct
entry
Copy and paste the results to
LMS report and verify correct
entry
Print out the LMS report and check
for errors
Print out the LMS report and check
for errors
Prepare and print out the repeat list for sample removal from
LMS
Prepare and print out the repeat list for sample removal from
LMS
Copy request form for repeat sample for next
batch and complete the
report
Copy request form for repeat sample for next
batch and complete the
report
Second licensed Molecular tech
check the prepared report
Second licensed Molecular tech
check the prepared report
Report correct?Report
correct?
Manger/Director review
Manger/Director review
Correct report Correct report
No
Yes
Send to sign out by MD
Send to sign out by MD
Report correct?Report
correct?Release reportRelease reportYes
No
Stamp and sign the printouts And the document
Stamp and sign the printouts And the document
Wait Rework
Muri
Wait Rework
Muri
Wait Rework
Muri
Wait Rework
Muri
Wait Rework
MuriWait
Rework Muri
Wait Rework
Muri
Wait Rework
Muri
Wait Rework
Muri
Print out WSD to highlight the
repeats
Print out WSD to highlight the
repeats
5 min/batch30 min/batch90 min/batch
5 min/batch 30 min/batch60 min/batch
30 min/batch60 min/batch90 min/batch
10 min/batch30 min/batch
10 min/batch
5 min/batch
30 min/batch
30 min/batch
90 min/batch
10 min/batch- 50% incorrect
10 min/batch10% of reports
10 min/batch 90 min/batch30 min/batch
15 min wait
30 min wait
720 min wait
60 min wait
60 min wait
120 min wait
10 min wait
720 min wait
Lean Improvements in Genetics Lab
Current SMFuture SM (W/O
GLIS)Future SM (With
GLIS)Ideal SM
Touch time 1.7 hours/sample1.55 hours/sample
(8.8%)1.1 hour/sample
(35%)30 min/sample
Cost (approximate) 100% 94.3% 65.4% 43%
Quality Mod Mod High High
Frustration of lab staff High High Low Low
Frustration of MD & patient
High High Mod Low
35© LMU SELP 695, Dr. Oppenheim
Lean Improvements in Genetics Lab
Lean Improvements in Genetics FISH Lab
36
Current State MapFuture State Map
without Genetics LISFuture State Map with
Genetics LISIdeal State Map
Throughput time 10 days 5 days 3 days 1 day
Quality Moderate Moderate High High
Frustration of lab staff High Moderate Low Low
Frustration of MD & patient
High Moderate Low Low
Lean Improvements in Genetics FISH Lab
37
Lean Improvements in Automated Chemistry Lab
SELP 695 - Capstone Project 2014 39
Lean Improvements in Automated Chemistry lab
SELP 695 - Capstone Project 2014 40
• Stagger the work on the instruments: Perform maintenance, reagent replenishment, calibration and quality control one analyzer at a time Enables continuous testing Maximizes throughput
• SPD to loads samples directly onto instrument racks (HbA1c, MAU), eliminating manual sample transfers between multiple rack types.
• Hourly sample delivery from SPD.• Auto-release the majority of results based upon rule-based algorithms.• Eliminate wasteful Hemastix testing (study justified during LEAN
observations)• Improve throughput• Provide training and tools to employees to ensure correct sample
collection
Lean Improvements in Automated Chemistry lab
SELP 695 - Capstone Project 2014 41
Lean Improvements in Automated Chemistry
Current State Ideal State Future State
Throughput Time (Olympus) 733.5 minutes 36 minutes 140.5 minutes
Cost Savings Baseline $1,570,976.50 $994,876.50
Quality Mod High High
Frustration of Lab Staff HIGH Low Moderate
Frustration of MD Mod Low Mod
Frustration of Patient High Low Mod
Lean Improvements in Microbiology Lab
Excessive batching and storage
42
SELP 695 - Capstone Project 2014 43
• Deliver trays of instrument-ready racks directly to each instrument area and eliminate the cabinet storage
• Improve lab layout • Expand hours• Use smaller batch sizes• Enable testing and result verification for up to 2,000
specimens verses 500 specimens on the day of testing.
Lean Improvements in Microbiology Lab
SELP 695 - Capstone Project 2014 44
Future
Testing is performed on all
instruments
Instrument-ready trays of specimens are delivered on carts
directly to the instrument sites
in Virology
START
END
Three CLSs are assigned, to prepare the three TIGRIS instruments
for testing.
Specimen racks are continuously loaded onto the instruments
Results for all 2,000 CT/GC specimens loaded
are verified before the end
of the day
Each of the three CLSs loads the first specimen
racks onto the instrument immediately
on completion of the daily PM.
The three stages of the post-analytical specimen discard,
rack bleaching/rinsing/ drying, and loading onto trays for
return to the SPD are located in close proximity, saving
processing time and steps
Specimen racks are removed from
instrument and placed back on carts
WASTEIDENTIFIED
6.5 hours
Testing of samples performed
Specimen Processing delivers Instrument-
ready trays of specimens to Virology at 5 a.m. and 10 a.m.
START
END
10 minutes
Specimen Processing places Itrays of specimens
in cabinet
90 minutes
CLSs loads specimen racks onto instrument (7:00 a.m. through 3:30
p.m.)
Results for 500 of the 2,000 CT/GC specimens loaded are verified before the end
of the day
Results for the remaining 1,500 CT/GC specimens are verified the following
day, Monday-Friday
Waste Identified
10 minutes
CLS moves trays of specimens to carts
and rolls to instrument
10 minutes
Specimen racks are removed from the
instrument and placed back on carts
90 minutes
CLS prepares instruments for
testing
Specimens are pulled for repeat testing as
needed
Cart of racks is rolled to discard area and
specimens are discarded
Specimen racks are washed, dried, and transported back to
testing area
WASTE
WASTE IDENTIFIED
Lean Improvements in Microbiology Lab
Current
Lean Improvements in Microbiology Lab
45
SELP 695 - Capstone Project 2014 46
Current State Future State
Throughput Time (Virology) 57 hours 13.5 hours(76%)
Test Quality Optimal Optimal
Patient Complaints ↑ ↓
Provider Complaints ↑ ↓
Employee Morale ↓ ↑
Lean Improvements in Microbiology Lab
Lean Improvements in Sample Collection in Medical Centers
© LMU SELP 201447
CSM FSM ISM
Throughput Time 696 minutes 350 minutes 90 minutes
Cost Savings Annually (approximate)
$ 0 $ 37,950/year (Rejection rate lowered by 10%)
$39,750/year(Rejection rate lowered 50%)
Errors on Specimen Processing
High Medium- High Low
Frustration of Lab Staff High Medium- High Low
Frustration of MDs & Patients
High High Low
Lean Improvements in Sample Collection in Medical Centers
48
6. Summary
Summary• US Healthcare has great elements: R&D, equipment, facilities,
medical schools, dedicated professionals• Yet, ranks last in healthcare delivery international rankings
• And the costs are huge and unsustainable • In order to improve it, Healthcare must be seen as a highly
complex System, and we need to use Systems Thinking• Lean must be a critical part of Healthcare Systems
• Hard evidence presented that Lean is highly effective in reducing waste and costs, and improving quality and throughput.
• LMU-KP Partnership demonstrated significant benefits
Lean does not tell MD and other medical professionals how to treat patients – it frees them to
do it more and better