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Don't Lose Patients

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DontLosePatients
Hybridapproachhelpshospitalstreamlinekeyprocess
byToddCreasyandSarahRamey

SarahRamey
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Concernedaboutinefficienciesinakeyprocess,ahospitalcombinedleanSix Sigmaandthetheoryofconstraintstoidentifyandeliminatebottlenecks.

Casestudy Healthcare SixSigma Goldratt'sTheoryof Constraints(TOC) Hospitals Processimprovement Continuousprocess improvement(CPI) Bottlenecks Healthcareindustry Customerloyalty

Asaresult,thehospitalcutwaittimeforitspatientsby70%andeliminatedthe maincauseofcustomersseekingotherproviders.

ClinchValleyMedicalCenteraforprofit,175bedhospitaloperatingin westernVirginiaandpartofahealthcareorganizationwithoperationsin18 stateshasbeenundertakingleanSixSigmainitiativesforaboutthreeyears. Duringitscontinuousimprovementefforts,thehospitalemployedtheprinciples of6TOC1 acombinationofleanSixSigmaandthetheoryofconstraints (TOC)2 inwhichorganizationsresolveprocessflowconstraintsorbottlenecksin aservicedeliverysystemwithleanandSixSigmatools. Thehospitalsseniormanagementteamdecidedtofocusonthepreadmission testing(PAT)processaspartofthehospitalscontinuousimprovementinitiative. PATevaluates,assesses,educates,andpreparespatientsandfamiliesfor successfulandsafehospitalexperiences.Alongwiththeemergency department,theseservicesareacornerstonetohospitalrevenue. PATisthefrontdoortoapatientsexperienceinanyhospitalandprovides patientstheirfirstimpressionofthehospitalandservicesrendered.Nearlyall outpatientproceduresareconsideredelectivesurgeryinthatpatientscanselect thehospitalorganizationatwhichtheywishtoreceivethesurgicalprocedure.A poorPATexperiencecansendthepotentialpatientelsewhere. PATisalsoavitalpartoftheprocessforoperatingroom(OR)clinicians.During PAT,allofapatientspertinentinformationiscollectedmedicalhistory,current medications,labresultsandelectrocardiograms.Withoutastreamlinedprocess, oneormoreoftheseaspectscanbeinadvertentlyomitted.Thisomissioncan resultindelayedsurgeryorcancellation,leadingtolostrevenue.

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Hearingvoices
ThePATprocessatClinchValleyMedicalCenterbeginswiththepatients physiciancontactingthehospitalandschedulingasurgeryappointment.It concludeswiththepatientarrivinghomefromthehospitalafterhavinghealth andprescriptionreviews,proceduresscheduled,andanynecessaryXraysand laboratorytestsconducted. ThelistofstakeholdersforthePATprocessincludespatients,physicians, nurses,PATassessors,labtechnicians,ORschedulers,themedicalrecords department,hospitaladmissionsandotheremployeesinthephysiciansoffice. Basedonthefactthatcustomerexperiencecanenhanceanorganizations revenueandmarginsandcanhelporganizationsdifferentiatethemselves throughtotalcustomerexperience,3 voiceofthecustomer(VOC)datawere collectedfromthesePATstakeholders.Itwasdeterminedtheprocesshadsix areasofconcern: 1. Patienteducation.Patientsdidntunderstandtheirfinancial obligationsandwerentbeingeducatedaboutthepreadmission processandultimateoutcome. 2. Effectivecommunication.Throughouttheprocess,therewasnt effectivecommunicationthatincludedtheexternalphysician,PAT nurse,hospitalcoordinatorsandpatient. 3. Patientscheduling.Patientswerevisitingthehospitalinveryerratic

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patternsandnotinaconsistentflow. 4. Waiting.Patientswereexperiencingexcessivewaittimes,andtheir timeinthehospitalwasnotbeingmanagedwell. 5. Documentation.Documentswerebeingreproducedtwoandthree timesforvariousdepartmentsinthehospital. 6. Bottlenecks.Theprocessproducedexcessiveamountsofworkin processinformationbackupsandpatientdelays. Asaresultoftheseproblemareas,thePATprocesswasdeterminedtobetime consumingandapotentialcontributortopatientdissatisfaction.

Processexploration
Withthreemonthstoimprovetheprocess,thehospitalcollectedasamplesize of62consecutivepatientexperiencesduringoneweek.ThePATprocesshad anaverageunnecessarypatientwaittimeofabout20minutes(standard deviationofabout18minutes),withsomewaitsexceedinganhour.Thegoalof thePATprojectwastoreducepatientwaittimeby30%. Theimprovementdrivecontinuedwiththeconstructionofahighlevelprocess flowchartthatincludedasuppliers,inputs,processes,outputsandcustomers (SIPOC)diagram(Table1).ThecriticaltoqualityareaswithintheSIPOCdealt primarilywithpatienteducation,prescreeningaccuracy,stakeholder communicationandschedulingofthesurgicalprocedure.

Thecolumninthetablemarked"Process"affordsahighlevelviewofthePAT procedure.TheruleofthumbforSIPOCswheninitiallyconsideringtheprocess columnisnottoexceedfourtosevenhorizontallevels.Thistypeofprocess documentingactivitycanleadtoabetterunderstandingoftheprocessand identifypossibleimprovementalternatives. WitharoomfullofPATstakeholdersfollowingthe6TOCprinciples,theprocess wasdissectedatahighlevel(Figure1).Aprocessflowchartwascreated indicatingnaturalprocessbreakpointsandwhichGreenBelt(GB)teamwould attendtothatportionsimprovementneeds.

Whenthisprocesswasmapped,thestakeholderswereaskedtoidentify bottleneckswithintheprocess.ThisiswhereTOCanditsfivebasictenets proveduseful: 1. Identifythebottleneck. 2. Exploitthebottleneck(getthemostoutofit). 3. Subordinatethesystemtothespeedofthebottlenecksflow. 4. Alleviatethebottleneck(makesignificantchangesthatreduceor eliminatethebottleneck). 5. Beginidentifyingmorebottlenecks. Thebottleneckswereidentifiedas: Step6SurgeonsofficeinformingpatientofPATdateandsurgery information. Step8Patienttimeinwaitingroomwithbeeper. Step10Preregistrationandthecollectionofpatientinformationor payment. Step15Startofpatientassessment. Steps1819DirectionandeducationregardinglaboratorytestandX rays. Thisprocessissimilartotheexplanationofhealthcareasachainofhandoffs.4 Bottleneckswereconsideredalongwithnaturalbreaksintheprocesstoportion outthesmallersegmentsthatcomprisethelargerPATprocess. BeforethegroupsofstakeholderswerereleasedandGBsformallyassignedto eachsectionoftheprocess,theteamexploredearlyimprovementideasby usingafunctionaldeploymentmatrix(FDM).Similartoaprioritizationmatrix,5 an FDMisaquantitativemethodforbrainstormingnecessaryinputsanddesired outputsusingasimple,twodimensionalformat. Table2liststhekeyprocessinputvariablesandkeyprocessoutputvariablesas determinedbythePATstakeholderswhoconstructedanFDMduringanallday meeting.

Improvementinitiatives
ThePATimprovementteampursuedbottleneckexploitationoreliminationusing

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leanSixSigmatoolsandfollowedthesesevenimprovementsteps: 1. Threepaperbasedformseachcontainingtwopagesandone computerbasedformwerecombinedintoasinglecomputerbased form.ThiseliminatedworkredundancybythePATnurseandalso speduptheprocesstimeforeachpatient,thusreducingtotaltimein thePATsystem. 2. Becausetherewasaninformationgapbetweenthelocal,referring clinicsandthehospitalsinternalpracticesandprocesses,thepatient informationbookletwasrevisedandreformattedforusewith surroundingclinics.BasedonclinicianVOC,acommunicationguide wasconstructedtoenableofficeadministratorsandclinicianstobetter understandthehospitalsinternalprocessneedsandtoeducate patients. 3. Thedeliveryprocessbywhichlocalclinicsforwardpatientchartsto thehospitalwaschanged.Formerly,thepatientwasresponsiblefor deliveringthecharttothehospital,whichresultedinadministrative delays.ByusingVOCfromoneoftheclinics,thischartacquisition bottleneckwasalleviated.Acouriernowpicksupallpatientcharts dailyfromsurroundingclinicsanddeliversthemtothehospital. Reducingchartdeliveryvariationinthisprocesshasresultedinno lostpatientchartsorpaperwork. 4. Theinternalmethodbywhichthepatientscharttravelsfromhospital registrationtothePATnursewaschanged.Previously,thePATnurse wouldretrievethechartfromregistrationandescortthepatienttoa doctorsoffice.Inanefforttoreducepatientwaitingtime,amemberof theregistrationgroupwalksthepatientandpertinentcharttothePAT nurseaftercompletionofpatientregistration.Thisprocess standardizationhaseliminatedthebottleneck,improved communicationanddramaticallyreducedwaittime. 5. Patienttransportwasredesigned.Formerly,thepatientwouldtravel fromthePATareatoradiologyorthelabforXraysorspecimen collection.Adheringtoleanprinciples,apatientmovementstepwas removed.Now,thePATnursedrawsthespecimen,thuseliminating specimencollectionbottlenecks,andtransportsthepatientto radiologyifnecessary. 6. Theprocessforcollectingpatientprescriptioninformationwas altered.Formerly,ifthepatientdidnotbringacompletelistofcurrent medicationstothehospital,thePATnursewouldcalllocal pharmaciesandconstructanaccuratelistwhilethepatientwaited. Withthenewstandardizedprocess,thePATnurseschedulestimeat theendofthedaytocontactthepertinentpharmaciesforspecific patientinformation.Notrequiringpatientstowaitwhilemakingcalls reducedpatientwaittime. 7. WithinthehospitalsITgroup,acustombuiltpatienttrackingsystem wasdevelopedtoserveasasignalingdevice.Thissystemalertsthe nursesinoutpatientsurgeryofabottleneckinthePATarea.After beingnotified,anursearrivestoalleviatethebottleneckand associatedstress.Applyinghumanresourcesintimesofpeakpatient inflowexploitsthebottleneckscapacityforservice,thusreducing patientwaittimes. Removingprocessstepsorcombiningstepsforsynergyssakeareatenetof lean.Thenewprocesshas17steps(Figure2)comparedwiththeformer,which had20.

Moreimportantly,apostimprovementsamplesizeof61consecutivepatients duringthecourseofoneweektwomonthsaftertheprojectwasinitiatedand improvementsbeganrevealedtheaveragepatientwaittimedroppedfrom about20minutestojustundersixminutes,areductionofaround70%. Inaddition,thestandarddeviationnarrowedfrom18.9minutestojustunder6.3 minutes,a67%reduction.Theeffectoftheseprocesschangesisillustratedin Figures3and4intheformofboxplots.

Provingimprovement
Practitionersofprocessimprovementaresometimesperplexedattheoutcomes resultingfromtheirlabors.Theywonderwhethertheperformanceafterthe improvementchangeistrulydifferentthanthebaselinedataorissimplya processoperatingonagoodday. Theanswerlieswithatwosamplettest,6 whichanalyzesdataunderthe assumptionthepopulationsfromwhichthesamplesaredrawnarenotdifferent (thestatisticaldifferencebetweenthepopulationsmeaniszero),andtherefore

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theprocesshasntchangedstatistically.

Don't Lose Patients

Apvalueofgreaterthan5%(assuminga95%significancelevel)indicatesthe comparatorsamplesmayactuallybefromthesamepopulationhenceno significantchangeintheprocess.Pvaluesoflessthan5%,however,are indicativeofthedatasetsnotbeingtakenfromthesamepopulationandsuggest thepostprocessimprovementsampleissignificantlydifferent. Thistestquantitativelyillustrateswhatallimprovementpractitionersdesireto know:theprocesshasimproved,andthetimeandenergyinvestedwerenotin vain. Afterexaminingtheresultsofthetwosamplettest,ClinchValleyMedical Centerdiscoveredthepvaluewas0(confidenceintervalformeandifference= 8.52,18.61).Atestofequalvariance(hypothesizingthevariationswerethe same)providedapvalueof0fortwoother statisticaltests:anftestandaLevenestest. Again,thissuggeststhesamplescamefromdifferentpopulations,implyingthe GBteammadeadifferenceinthehospitalsPATprocess.Figures3and4 providegraphicalevidenceofthisoutcome.

Whatdidwelearn?
Thehospitaltookawayfivelessonsfromthisproject: 1.Aneasysolutionisnotalwaysagoodsolution.Whatisconsidered straightforwardmaynotaccountforallthedependencieswithinaprocess.For example,thestakeholderdepartmentsreliedheavilyonthePATnurseto managetheprocess.Althoughstraightforward,thiswasnotthebestsolution. Also,patientswereaskedtobringtheirownpaperworkwiththemtothehospital. Thisresultedinincompleteormissinginformation.Adailycourierserviceto eachpatientsprimarycarephysicianremediedthisproblem. 2.Itstheprocess,notthepeople.Professionalstaffworkingwithinaprocess oftenforyearscantakeownership,whichcantranslatetoprofessionalidentity. Tweakingtheprocessmeansadjustingtheirresponsibilitiesorcovertly conveyingtheyhavebeendoingitwrongforyears.Tactandfinesseare requiredtoovercomethisobstacle. Forexample,thePATnursehadbeenmanagingtheprocessaloneformore thanfiveyearsandhadbeenahospitalemployeeforabout30years.Initially, hewasntopentosuggestionsorprocessmodifications.Hetookprideinhis responsibilitiesandhaddifficultyseeingtheneedforimprovement.Focusingon theprocessratherthanthepersonhelpedchangethatperspective. 3.Gooddataarekey.Datahaveawayofdrainingalltheemotionoutofthe room.Butvaliddataenableteamproductivity.ThePATnurseheavilyassociated hisidentitytohisworktasks.Oneweekofinitialwaittimedata,withsubsequent weeklydatafollowupfortwomonths,helpedconvincehimoftheneedfor change. 4.Getyourhandsdirty.Unlessyougetinvolvedwiththedaytodayoperations, youmaynevergetanaccurateassessmentoftheinnerworkingsofaprocess. Fewsolutionscancomefromanuninvolvedprojectteam.GBsfromtheteam accompaniedthePATnurseandcollectedprocesswaittimedatadailywith standardizedforms. 5.Seetheresultsquickly.Successbreedsmomentum.Asisoftenthecase withprocessesthathavemultipletransferpoints,momentumisrequiredtoreach thetippingpointandbeyond.Throughouttheimprovementprocess,patient waittimedatawerecollectedweekly,trendedandreportedtothePATnurse andhissupervisor.Thisconstantprocessattentionthroughdataprovedtobe invaluable. Inthefuture,hospitalreimbursementsfromMedicaidandMedicarewillalign evenfurtherwithimprovedperformancestandards.Withtheadventofthe consumerpatientconceptduetotherisingpopularityofconsumerdrivenhealth plans,hospitalpatientswillstartbecomingmorepricecentric. Thiswillforcehospitaladministratorstofocusintentlyonallimprovement opportunitiestohelpdrivedownprice,thusattractingpatientswhileenhancing qualityeffortstoreceivemaximumreimbursementfromtheU.S.government. The6TOCapproachcanaidadministratorsintheirquesttodeliverabetter healthcaremodel,whichprovidesabetterpatientexperienceandimproves qualityofcare.

References

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1. ToddCreasy,"PyramidPower,"QualityProgress,June2009,pp.40 45. 2. JeffCoxandEliyahuM.Goldratt,TheGoal:AProcessofOngoing Improvement,NorthRiverPress,1986. 3. JohnGoodman,"TakingtheWheel,"QualityProgress,February2012, pp.4247. 4. EdwardChaplin,"ReengineeringinHealthCare,"QualityProgress, October1996,pp.105109. 5. JackReVelle,"MakingtheConnection,"QualityProgress,July2010, pp.3644. 6. DavidFreedman,RogerPurvesandRobertPisani,Statistics,third edition,WWNortonandCo.,1998,pp.127129. ToddCreasyisanassociateprofessoratWesternCarolinaUniversityin Cullowhee,NC,andaconsultant.Heearnedadoctorateinmanagementfrom CaseWesternReserveUniversityinCleveland.AnASQmember,Creasyisa certifiedSixSigmaBlackBelt. SarahRameyisaclinicalpharmacistatClinchValleyMedicalCenterin Richlands,VA.SheearnedadoctorateinpharmacyfromClinchValleyMedical Center.

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