REDESIGNING ALLIED HEALTH OUTPATIENTS - Lean …proceedings.com.au/nahc/presentations...
Transcript of REDESIGNING ALLIED HEALTH OUTPATIENTS - Lean …proceedings.com.au/nahc/presentations...
REDESIGNING ALLIED HEALTH OUTPATIENTS- Lean Thinking Applications to Allied Health
• Josephine Kitch, Director , Allied Health Division ,Flinders Medical Centre , SA• Brenda Crane , RDC Clinical Facilitator , Allied Health Division,FMC, SA• Prof. David Ben Tovim , Director , Redesigning Care, FMC• Rebecca Daebeler , Manager , Podiatry Department,Allied Health Division ,FMC , SA
BACKGROUND
• Flinders Medical Centre– Approx 530 Beds
– Public teaching hospital
– Co located with FUSA & Flinders Private Hospital
– Within Southern Adelaide Health Service
– Full range of care from Perinatal to Palliative
– One of 2 Major Trauma Centres in SA
– Largely emergency driven work – busiest ED workload/bed ratio in SA
WHY DID FMC UNDERTAKE REDESIGNING CARE ?
- Had to search for unfamiliar solutions • Learned about Lean Thinking • British National Health Service Modernisation Agency • Lean Manufacturing sources – local & international
Winter 2003 …………–Major crisis ensuring safe care
–Increasing our capacity did not work !
– Launched Redesigning Care Programme
REDESIGN IN FMC• First 18 months – Adult Emergency Dept
– Identified sequences of care -Value Streams – Process made visible – Big Picture Map– Patients seen in order of arrivalRESULT :Hospital Brought under control
– Can see extra 20 patients per day in ED– Congestion decreased– DNA fell – 7% to 3-4%– Improved ward turnover –1010 bed days saved – Restored capacity for Elective Surgery – Morale & recruitment improved – Other streams – Medical , Surgical, Mental Health , Older Patient
WHAT IS REDESIGNINGCARE ?
– A systematic change programme
– Based on Lean Thinking philosophy & tools
– Focus on making visible the complexity of thePatient Journey through care
Redesigning Care is :
• Can do culture -vs blame culture • Ongoing improvement• Sustainable change
WHAT IS REDESIGNING CARE ?It’s about :
•The Patient Journey(not departments,divisions or professionalsilos )
•Creating flow, maximising valueand reducing waste
•Participation and ownershipof staff ,who initiate change
•Managers as enablersnot decision makers & directors
•The” Flinders House”
WHAT IS LEAN THINKING ?• Based on the Toyota Production System • Well established methodology to organise complex
processes – Initiate change from workplace – Get the Right patient ,to the Right place ,for Right treatment ,
at the Right time
IT IS NOT
– A project management philosophy– A non specific QI process
• Specify Value from the standpoint of the end customer
• Identify the Value Stream for each product family
• Eliminate Waste• Maximise the Flow of the product or service • Enable the customer to Pull or engage the
service as needed • Manage towards Perfection
Adapted from “ The Toyota Way “ – Jeffrey K. Liker
FIVE PRINCIPLES OF LEAN THINKING
8 WASTES IN HEALTH CARE
• Waiting• Queues • Errors • Transportation • Motion • Over Processing• Over production • Not using the skills & expertise of staff doing the
jobAdapted from “ The Toyota Way “ – Jeffrey K. Liker 2004
REDESIGNING CARE
Program phases
P DA C
12
3
45
Diagnostic Diagnostic PhasePhase
Project Project PhasePhase
Sustain Sustain new waysnew waysof workingof working
Share key Share key learningslearnings
Intervention Intervention PhasePhase
P DA C
P DA C
P DA C
P DA C
REDESIGNING CARE PROJECT PHASE
1. Identify a piece of work that needs doing that is aligned with program goals / targets
2. Endorsement by the hospital executive3. Steering Group / Leadership group 4. Defining the targets 5. Establishing the work-groups / resources6. Lean education
Project Project PhasePhase
Diagnostic Diagnostic PhasePhase
• Big picture map- “current state”• Identifying and acknowledging the mess• Engagement and permission of staff
• Identify the value streams (or ‘a’ value stream)
• Establish value stream work group
• Map specific value stream• More detailed understanding of a specific patientjourney
•Track the patient journey•Is what we think happens, what really happens?
•“Future state “map
DIAGNOSTIC PHASEUnderstanding what is happening now……….the good, the bad & the ugly!
Intervention Intervention PhasePhase
P D
A C
REDESIGNING CARE INTERVENTION PHASE
• Work towards a future state through a series of PDCA cycles
• Targeted interventions revealed through mapping processes
• Sometimes it is important to get started• Access to real time data on a weekly basis• 3 month cycles
FMC Allied Health Outpatient Service
is a large business
operating ina complex hospital
system
ALLIED HEALTH REDESIGN•How does this apply to us ?
ALLIED HEALTH REDESIGN
Project Phase• Ever increasing demand on Allied Health
Outpatient Services in FMC • Explore Lean Thinking methodology to
– understand our services– identify duplication and inherent waste – learn how to improve processes .
• Steering Group formed and a Clinical Facilitator engaged in July 2006
ALLIED HEALTH REDESIGNDiagnostic Phase
An initial survey of the FMC Allied Health OP Service showed:
• Complexity • A large business ( the Allied Health Division )
– comprised of 8 smaller individual enterprises• No single Allied Health Outpatient entity and location • No standard operating processes across the Division • Diversity in size , staffing , funding and partnership
arrangements• Disparate referral processes• Organic growth -adapting to department rather than
organisation wide issues
ALLIED HEALTH REDESIGN Diagnostic phase
Mapping:-• Compare largest and smallest Departments ( Physiotherapy & Podiatry) in August – September 06
– Array of hidden roles and assumptions. – Complexity and variation in clinic scheduling – Embedded “ knowledge work” in scheduling
• vulnerable PMA & Assistant & Admin roles
– Disjointed linking with other clinics or “production lines “across FMC
– Access issues for low risk patients in a context of shrinking community options
…another complex system quietly feeding into the main FMC “pipes “ or streams…. …….
The Podiatry Dept. is …..
ALLIED HEALTH REDESIGN
PODIATRY INTERVENTION -DiagnosticsBaseline data analysis• Incomputable complexity of scheduling 12 specialised
Podiatry clinics. • Tracking of Podiatrist and PMA/Administration roles
– high value adding by podiatrists – team dependence upon multitasking PMA /Clerical
role • Valuable information
– continual motion of PMA – PMA activity & overburden – Information flow – Patient wait times
PODIATRY INTERVENTION Diagnostic phase
Podiatry PMA Activity (one clinic )
VANVANDVBREAK
Staff Cover for PMA (one clinic)
02468
AM set up
Calls
Bookings Clea
ningDres
sings
Activity
Inst
ance
s
Podiatry PMA Instances of Activity ( one clinic)
020406080
100120
Movement Opera
tions
Info. flow
Interruptio
ns Clean
ing Ass
ist Pod.
Assist D
r
activity
inst
ance
s no
ted
•Tracking Podiatry PMA
PODIATRY INTERVENTION Diagnostic Phase
Podiatrist Activity Value Chart (one clinic)
VANVANDVBreak
Patient Wait Time (one clinic)
010203040
1 2 3 4 5 6 7
Patient
Min
utes
Wai
ting
•Tracking Podiatrist
Podiatrist instances of Activity (one clinic)
05
1015202530354045
Movemen
t Ope
ration
sInter
ruptions
Info flo
w Rew
ork
PODIATRY INTERVENTION- BOOKING TEMPLATE REDESIGN • Aim :• Simplify the complex booking & triage system
through redesign of clinic booking template• Release capacity for IP work and OP High Risk
service from gains made from improved OP Clinic flow.
• Work Group - October 2006 • Trial Intervention -Feb. 2007 ongoing
PODIATRY INTERVENTIONBOOKING TEMPLATE REDESIGN • Method:• Move bookings from computer template • Single large hand written daily template sheet• All staff to see all patients • No named clinics• Book to time needed , treatment room, & Podiatrist• Multiples of 20 min (later10) slot units - not set
appointment length• Book patients in order to next available appointment • Pre allocated emergency slots in each session• Plan Do Check (Study) Act cycles for review and
planning
PODIATRY INTERVENTIONBOOKING TEMPLATE REDESIGN• Booking Model
Referral
Slots in Order•All staff see all pts
•No named clinics
•Next available appt
•See pts in order
•Emergency slots
PodiatristTriage &
Assessment &Decision reFollow up
10
10
10
10
10
10
10
10
10
10
Variable
Slots
PODIATRY INTERVENTION-Cycle checks
• Check - 30/3/07• Helps in staff
vacancy.• +‘ve use of small
gaps • Template to
computer
Check- 1/2/07•20 min to 10 min slots •Increased flexibility • Written sheets to book
•Check- 20/4/07•Visible template•Aids time management•Easy to use •Immediate access to info•Visual control tool for scheduling work•Adjustment to variable slots takes time •Some set clinic times for specialist link up
Check 28/5/07
•Capacity freed for IP work
•Consider optimum ,rather than set time slots ,for New pts
•Increasing patient variety in Specialist Clinic.
•Now consider workplace redesign -5S
PODIATRY BOOKING INTERVENTIONStaff Feedback•Template easy to use -visual control •Flexibility of 10 minute slots
–Adjustment required to anticipating right time for booking–Positive use of small gaps
•Improved range of appts across week for patients•Benefits of move away from specialist clinic structure
–Patients easing away from familiar clinic & day •Enhanced capacity for inpatient work
–Now possible to see IP’s on same day –Enhanced rapport with ward staff–All staff get IP experience now
•Generalist and Specialist Podiatrist skills confirmed across team–Helpful in time of vacancy , not lost when staff leave
PODIATRY INTERVENTIONResults • Demand Tally • Pre Intervention Post Intervention
2006
70% offered appts
2007
88% offered appts
15 days
Av.wait to appt
10 days
Av.wait to appt
Range 2-27 days Range 5-16 days
Wait cut by one week
Compressed range of wait advantages ALL patients
PODIATRY INTERVENTIONResults- Activity Data Comparison-Pre & Post Intervention
2007Staff instability & leave significantly greater than 06
But lower in 2007
Activity Maintained
DNA rate fell steadily over both periods
Podiatry DNA 06 & 07
0
10
20
30
40
Feb Mar April
DNA 06
DNA 07
PODIATRY INTERVENTION -Laboratory 5S• Sort
Identify what’s needed and not – Sometimes used – Rarely used – Never used – Red Tag – Eliminate clutter
• Set in Order
For access & to relate to process– Analyse status quo– Allocate items a space – Decide how things should be stored – Labels
• Shine
– Clean , inspect & maintain work area
– Identify hazards
• Standardise
Make work areas with similar function look the same
Visual techniques – Quick identification
– Place for everything – Easy retrieval of frequently used items – Check list for putting things away
Safe storage – height & weight considerations
• Sustain
Ensure 5S is not just a quick clean up Team responsibility5min maintenance daily
Standard operating procedures
5S teams
PODIATRY LAB 5S
Before
After
PODIATRY LAB 5SBefore
After
PODIATRY LAB - 5S
Before After
Ongoing Planning in Podiatry
• Consumer feedback and satisfaction• Investigate patient outcome data• 5S all areas of podiatry area• Consolidate changes made in the department• Continue to improve• Continue to share
ADDITIONAL ALLIED HEALTH WORK
• Big Picture Maps completed for all AH OP Services
• Booking Intervention - Audiology Dept since May 07
• Hand Therapy Service mapped in June
• Links with Division of Surgery -hospital wide OP Referral Data Base – pilot site Dietetics
• AH key member of Hospital Outpatient Steering Group and in some areas leading the way
Hospital wide Outpatient framework
• Principles• Metrics• Predicated outcomes• Across the outpatient journey points (referral,
triage, booking, intervention and discharge)• Endorsed by Management Executive• Now the fun begins!!• Standardization is possible across the hospital
SUSTAINING NEW WAYS OF WORKING
• Culture of perpetual improvement Make friends with your data!
• Team ownership of the process • Develop Lean Leaders in each department
Staff coaching and Lean knowledge • Learning by sharing - success and failures• Workplace organisation 5S & shared responsibility