Lean Six Sigma Black Belt

Project Portfolio

Karen Carswell / Kamal Babrah

3/5/2015

Submitted project portfolio, required to achieve Lean Six Sigma Black Belt certification. Summary of work done with the North Bay Nurse Practitioner Led Clinic to improve Primary Care access, efficiency and process improvement.

Project I.D./Name: North Bay Nurse Practitioner Led Clinic NBNPLC Team Lead: Miranda WeingartnerStart Date: April 2013 Team Members: Shannon, Danielle, Nicole, LeeannePlanned End Date: December, 2014Approval: EZ Sigma – Rod Morgan, Master Black Belt HQO QI Specialists: Karen Carswell & Kamal Babrah

Define Issue/Problem and Describe Current State:

Background

Traditionally, physicians have provided the majority of primary care services, and unfortunately many Ontarians have not been able to access a family doctor. In order to meet this demand, Ontario is now able to offer a new type of clinic called Nurse Practitioner-Led Clinics. These are led by nurses who have additional training as Nurse Practitioners (NP’s) and who are trained to keep clients healthy for as long as possible.

North Bay Nurse Practitioner Led Clinic (NBNPLC) offers individual client centered care, and works with their clients to establish health goals, and then help them meet these goals. These can be for things like losing weight, living a more active lifestyle, managing stress, controlling blood pressure, receiving vaccinations, quitting smoking, feeling depressed or anxious, or having a check-up. Services are offered in English or French, depending on the client need. They provide services to those who do not have a healthcare provider and who wish to become a client of their clinic. They offer team based care, meaning that they offer the services of nurse practitioners, nurses, a physician, a dietitian, a social worker, and a pharmacist. A laboratory is on-site so clients may also have blood work done at the clinic.

NBNPLC was fully operational as of September 2012 and has a panel of 1902 clients and team of 4 FTE providers. Since being fully operational, intake of new referrals is on average 28 clients per month.

Current State

Shortly after being fully operational, there was a great deal of staff turnover due in part to changes in FTE status of the providers and having an interim executive director. Access to a provider and continuity of care was reduced due to inconsistency in provider supply. Supply from PTE providers did not match the demand of the clients. To improve continuity of care and better match provider supply to client demand, there was a move to change the status of all providers to full time. As a result, the supply became more consistent over the full work week and better matched provider supply to client demand.

NBNPLC tracks access to care using the indicator of Third Next Available (TNA). TNA is the sum of the days between the time a client requests an appointment and the time of the third next available appointment. Beginning in April 2014 they started to notice an increase in TNA for two of the four providers.

Portfolio of Opportunities for Improvement using the 8 Wastes

The new Executive Director and the team became concerned with access to care in April 2014. The following identified areas of opportunities for improvement is a compilation of processes that the team worked on to address their access and efficiency issues. They felt that the process was not efficient during the intake process and during the client visit. Using the 8 wastes, the team was able to identify areas for further analysis:

1) Wasted Time: With the creation of a value stream map, the team was able to identify the steps of the client experience that were non-value added to the client. Cycle time was used as an indicator to measure improvements in the non-value added wasted time during the client visit. Cycle time for a client visit was measured as 43 minutes with 12 minutes of non-value added wait time. The team was meeting their target of >50% face to face time with the client and wanted to maintain this ratio but reduce the overall cycle time. This would allow each provider to maintain the value add time to the client but increase their supply by one additional appointment per day per provider.

2) Delays in Time to Complete Administrative Tasks: The team identified two opportunities for day to day efficiency which impact indirect client care, they included examining administrative work and interruptions throughout the day. Administrative work related to client care was scheduled for providers on two time slots during each week. Client complaints in delays for completing paperwork (i.e. prescription renewal referrals, client forms etc.) motivated the team to understand the root cause of this delay. In addition, unplanned interruptions throughout the day reduced the time available for client care and increased the amount of administrative work at the end of each day.

3) New Client Intake Wait Time: In order to improve the wait time for new client intake, the team decided to change their intake process to a group intake as compared to individual client intake. The team hypothesized that group intake of new clients would improve the wait time for initial visits for new clients and help to reduce the wait list for new clients. The team was also interested in understanding the voice of the customer for this new approach to intake.

4) Extra Processing: With the use of a process map, opportunities for improvement were identified for the scanning process.

5) Process Defects: With improvements in access, the team was having difficulty understanding why they were not able to provide access to their providers was not occurring within 7 days of their clients being discharged from the hospital.

6) Data Collection Defects: An additional identified opportunity for this team and was related to data that was not being captured consistently for cancer screening (colorectal, cervical, breast). NBNPLC reports cancer screening data to the Ministry of Health and executive director was interested in brainstorming the causes of their inability to access reliable data from their EMR, which was resulting in rework. A Kaizen event was held with a cross functional team to create a standard process for capturing cancer screening data.

Analyze and Identify Root Causes/issues:

Each of the following items correspond to the above listed wastes.

1) Value Stream Map – A VSM was created to illustrate cycle time of a client visit. A client sample size of 27 was used to create the VSM. Average cycle time for a client visit over these samples was measured as 43 minutes with an average of 12 minutes of non-value added wait time. Since the ratio of face to face time (72%) and client wait time (28%) was within their target of >50%, the team identified the areas of check-in and time during the provider visit as opportunities to reduce cycle time and therefore increase provider supply.

SIPOC – After the value stream mapping, a SIPOC chart was created using the following boundaries for analysis; from the moment a client is referred to the NBNPLC to the end of their initial visit with the provider.

Provider / Supplier

Input Process Output Beneficiary / Recipient

Providers of resources

Resources required by process – specifications

High level description of activities

Deliverables of the process step

Recipient requirements on output

Who receives the output

Client, 3rd party on behalf of client

Schedule, EMR, Admin staff

Request for Clinical action - Time allocatedAny Reception

Client receives appointment, request for action received

Available time, timely appointment

Clinician

Medical Admin, other Clinician

Scheduler, Chart, health card, demographic form, Office room

Pre-admin / Client arrivalFront Reception

Chart Prep & Pull, Reminder call, Chart review.Client check in - info verification, socio demo

Notification of appointment, Planned and Prepared appointment.

Clinician, Client and CHC

Clinician(s) Chart, EMR, results, clear directives, available exam room & equipment

Action on request(s) - Client seen by Clinician

Assessment, Treatment, Plan formulated

Reason for visit or action understood and addressed

Client, 3rd party on behalf of client

Medical Admin, other Clinician

EMR / scheduler, printer, clear process, access to resources/ paperwork / process

Post Admin / Front Desk Reception

Plan, next steps, next appointments

Request/ action addressed - clear plan, next steps. e.g. Rx, booking slip, letter, form completed, referral

Client, 3rd party on behalf of client

2) 5 Whys – The 5 Whys tool was used to understand the root cause of delays in the completion of administrative work.

Why are there delays in completing administrative work (i.e. WSIB forms)?Providers were unable to complete administrative work during the client visit so work was set aside (batched) and completed at a later time.

Why?Providers completed administrative work only during two half day designated each week for administrative work.

Why?Scheduling design dictates the process of batching administrative work. Proposed solution: Revaluate how administrative time is scheduled.

Interruption Study – The providers tracked the type and frequency of unplanned interruptions each day and tracked the type of administrative tasks and the time needed to complete these tasks. This helped them to determine how much administrative time was needed each week for each provider and led to change ideas related to just in time work. This also provided them with some guidance for contingency planning for how much administrative time providers would require to catch up on these tasks after an absence due to vacation or other leave. Daily huddles with a checklist were implemented to minimize interruptions throughout the day, by creating a short meeting every morning to discuss emergent issues the majority of these interruptions became unnecessary. (See Appendix A for huddle checklist)

3) New Client Group Intake vs. Individual Intake

The team wanted to understand the impact of the group intake process that was implemented in April 2013 on the size of the wait list for new client intake. Since being fully operational in September 2012, the new client wait list has reduced from 2000 clients to a wait list of 841 clients. Prior to April 2013, the average number of client intake visits was 28 per month. After implementation of group intake process, the average number of client intake visits per month remains consistent at 28 per month. This data was considered to be positive by team because the rate of intake has remained unchanged but they have still received the benefit of creating additional supply in the provider schedule. Refer to Results Verification section for improvement analysis details.

4) Process Map – The analysis of the clinics process to scan documents into their client files in their EMR involved creating a current state process map. They collected data to determine the length of time required for scanning documents in two locations (reception and board room). The picture below is a portion of the current state process.

The team determined that on average scanning takes 3.47 minutes longer per document in the boardroom as compared to the reception area. After using a 2 sample t test, it was determined that there is no significant difference in the scanning time based on location.

2-Sample t Test: reception vs boardroom

Sample reception boardroom Est for Diff -8.46

N 5 595% Lower Bound -23.9447

Mean 9.16 17.6295% Upper Bound 7.0247

Std Dev 3.4861 11.9738 Test of diff =0 vs <>0

SE Mean 1.559 5.3548 DoF 4

T -1.5169

P Value 0.2039

Even though there was no significant difference in the time to scan documents based on location, the process map exercise helped the team to identify opportunities to streamline this process by removing unnecessary steps, hand offs and duplication of effort, no matter the location of the document scanning.

5) Fishbone Diagram – In order to dig deeper and understand why the team was having difficulty providing access to their clients within 7 days of being discharged from the hospital, the team used a fishbone diagram to identify the root causes (See Appendix B for Fishbone Diagram). Using expert clinician opinion to decide on the few key root causes, the team identified communication between providers and non-compliance of clients attending their scheduled appointments as the two key root causes. Nurse practitioners in primary care (as with NBNPLC) are required to have a collaborating physician for tasks that are out of scope and often these physicians are not co-located with the NPs. This relationship at times causes confusion from the hospital perspective and often the North Bay Regional Health Centre would notify the collaborating physician of client discharge information, unbeknownst to the NP.

6) Kaizen Event – To better understand the root cause of the cancer screening data collection defects the team decided to hold a Kaizen Event. The Kaizen event agenda, held on November 12, 2014, (See Appendix C for Kaizen Agenda) outlined the purpose of developing a new standard cancer screening data collection process. The Six Thinking Hats tool (See Appendix D for Debono’s Six Thinking Hats Tool) was used to generate creative thinking amongst the cross functional team, encouraging them to think outside of their usual roles. The tool allowed the team to discuss contentious issues about how and where data should be collected and by whom, in a safe environment, as they were ‘playing their assigned roles’. The output of the day was a flow map that details a new standard approach for cancer screening data collection (See Appendix E for Cancer Screening Data Collection Process Map).

Desired Future State:

Outcome Measure Baseline (Year 1-2012)

Target Actual2013

Actual2014

Average # New Client Intakes per month - Reported Annually

25 30 22 33

New Client Wait time to intake in Days - Reported Annually

309 Reduce the backlog on waitlist, then determine reasonable target. Desire a reduction

compared to baseline over time.

290 105

Process Measure Baseline (2013)

Target Actual To Date(Dec 2014)

TNA 7 0 4Cycle time Unavailable 35 43Face to face time Unavailable >50% of cycle time 72%

Solutions:

# Issue/Opportunity Short Term/Rapid Trial Metrics Longer Term (May require approval)

Metrics

1 Wasted Time During Client Visit

30 minutes client appointment will be reduced to 20 minutes

Cycle Time – maintain >50% face to face time

Standardizing process to do indirect administrative care during client visit (real time)

Time, in minutes, at end of each to require to compete administrative task for that day

2 Delays in Time to Complete Administrative Tasks

Morning Huddles to reduce daily interruptions

Huddle Time-Target of <15 minutes

# of daily interruptions

3 Client Wait Time for Intake

Group Intake Wait in Days for new intake appointment

Avg. # of Intakes per month

Reduce Backlog of Intake Wait List

# of Clients on Wait List

4 Efficient Scanning Process

Shift from batching to real time process

# of client reports waiting to be scanned in the EMR at the end of each day

Standard scanning process – flow map

Audit – % of Staff Adhering to standard process

5 Follow up within 7 Days of Discharge

Work with Hospital partners to create a process of discharge notification to NPs

# No Shows for Follow up Appointments

TNA

Data sharing – notifications to come directly to EMR

6 Kaizen- Cancer Screening

Standardize process of data collection in EMR

Audit - # of defects in data collection

Resolution Action Plan:

Wasted Time during Client Visit - 30 minutes client appointment will be reduced to 20 minutes – One NP is currently trialing different approaches to ensure that 20 minutes of the 30 minute appointment is face to face time with the client and that 10 minutes is used for administrative tasks associated with that client. This will ensure that administrative tasks are completed within the client time each day. This is reflected in her personal action plan, (see Appendix F for the NP’s Tree Diagram), which also addresses work life balance. Once her trial is completed successfully, they plan to test it with a second provider with the long term goal of standardizing it and spreading it to all providers. This provider will complete her trial by March 2015.

Delays in Time to Complete Administrative Tasks - Morning Huddles to reduce daily interruptions have been implemented and are working effectively, the team is very receptive to these short, focused meetings. The team has taken it a step further and now during that 15 minute meeting (see Appendix A for Huddle Checklist) they also review all new change ideas and prioritize them on an impact/effort tool and assign a lead. (see Appendix G for Impact/Effort Tool) The leads provide updates on all currently assigned PDSAs for change ideas.

Client Wait Time for Intake - Group Intake was implemented in April 2013, it was well received by the clients. They have collected client feedback after each group session. In summary of the survey results, clients were overwhelmingly positive with the group intake format, but on reflection the team felt that the survey tool was too open ended and not sensitive enough to pick up the areas of opportunity for improvement.

The team plans to engage clients in the redesign of the survey to better understand areas to ask more focused questions. Also, they are considering the use of a Likert scale for some elements to provide a scale and to assist with prioritization of issues.

The clinic is currently understaffed and until they have a full complement of NPs on staff they have stopped new client intakes. This will have an impact on both the average # of new client intakes per month and the average # of days wait time to client intake.

The staffing issue may also impact the total number of New Clients on the wait list for intake. This will add to the existing backlog. We recommend that the team consider contingency planning and mitigation strategies to address this backlog. This responsibility will be deferred to the Executive Director to consider the budget for the upcoming year to see is other resources may be funded.

Efficient Scanning Process – The team has implemented a new streamlined process, which has become their standard practice. (See Appendix H for Scanning Process Map) This shift from batching to a same day real time process has resulted in less frustration for all staff members and far fewer incidents of clients arriving for appointments with the team unprepared because they cannot locate test results or referral reports.

Follow up within 7 Days of Discharge - Work with Hospital partners to create a process of discharge notification to NPs is ongoing. Some short term solutions have been put in place. The team now has the ability to login to hospital information to search each day for client discharges, but they would like to continue to explore the option of data sharing and having this information sent directly to their EMR each day.

Cancer Screening Data Collection – After the Kaizen Event the team reviewed the change ideas and their action plan and struck a working group to develop a standard process. (See Appendix E for Process Map of Cancer Screening Data Collection) The team is currently providing staff education on the new process to review where and how the cancer screening data is captured in the EMR. Once training is complete this will become standard practice.

Results Verification and Benefits:

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13Jul-1

3

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14Jul-1

4

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

0

10

20

30

40

50

60

70

80

31

51

24 2328

32

8

1724 21

13

23

36

28

15 1418 19

35

67

52

2215 16

27

52

65

9

Count of Patient Intake by Month

Month

# of

Pati

ents

The outstanding concern for the team is the need to reduce the wait time to initial client intake. Although the number of client intakes per month has remained consistent, the goal for the team was to reduce the average client wait time for acceptance to the clinic. To accomplish this goal they will have to address the current backlog on the Wait List.

Wait List: 2000 Wait List: 841

Median wait pre Median wait post % of Decrease in Med wait361 148 59%

Normality Test: pre group intake

Mean 308.8 Std Dev 202.3253 N 10

AD 0.3915 P Value 0.3086

Normality Test: post group intake

Mean 171.0833 Std Dev 118.3542 N 12

AD 0.4382 P Value 0.2437

2-Sample t Test: pre group intake vs post group intake

Sample pre group intake post group intake Est for Diff 137.7167

N 10 1295% Lower Bound -18.9787

Mean 308.8 171.083395% Upper Bound 294.4121

Std Dev 202.3253 118.3542 Test of diff =0 vs <>0

SE Mean 63.9809 34.1659 DoF 13

T 1.8987

P Value 0.08

At a quick glance, the median wait time for acceptance to the clinic pre group intake and post group intake reflected a decrease of 59% in wait time. After analysis of the two groups, both groups have normally distributed data and when comparing the two groups using a 2 sample t test, there is no difference between the means of the two samples. This data helped the team to understand that there was no difference with the average length of wait post implementation of the group intake process. The team was initially surprised by this data and dug deeper to identify, that until the existing backlog of 841 clients waiting for intake was eliminated, the data may not reflect an improvement. Eliminating the backlog of client intake became an additional opportunity for improvement. Also, the staffing levels of providers was identified as a possible variable impacting the average wait time to client intake. More data will be required to fully understand this relationship.

Median: 361

April 2013: Group Orientation

Sustaining Actions:

The team will utilize the following strategies to ensure the gains achieved will be held:Sustaining Action

Visual Management Impact/effort tool is displayed in a common area and reviewed daily during huddleStandardization A standard document to record communication during a huddle has been implemented

Daily huddles will be scheduled into the provider calendars by reception on a daily basis Scanning process map Cancer screening data collection process map

Error-proofing Implementation of audits for cancer screening data collection process and scanning process

Metrics Monthly reporting of metrics include: TNA, no shows, supply and demand, wait time for new client intake, client intake wait list, cycle time.

Reports Review of key metrics by team on a monthly basis and quarterly basis by the Board. Ongoing training for staff for standard processes

Systems Management

Internal cross functional QI team meets once per month in order to create capacity by embedding and sustaining QI within the organization.

Meet regularly with external partners to discuss QI opportunities for improve integration, transitions and communication

Spread Develop a strategy to capture regular measurements on all providers In order to encourage a culture of sharing, display results in a transparent and easily

accessible way. Identify and target those providers displaying largest opportunity for improvement.

Listing of Appendices

Appendix A: Huddle Checklist

Appendix B: Fishbone Diagram

Appendix C: Kaizen Agenda

Appendix D: Six Thinking Hats Tool

Appendix E: Cancer Screening Data Collection Process Map

Appendix F: Tree Diagram

Appendix G: Impact/Effort Tool

Appendix H: Scanning Process Map