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November 6th, 2006
Effective Use of the Tool Box in Healthcare
Adrienne Elberfeld, Master Black Belt Virtua Health,
Marlton, New JerseyMarch 29th, 2007
November 6th, 2006
Virtua Facilities
November 6th, 2006
Virtua Health….TodayFour hospital system in Southern New JerseyTwo Long Term Care FacilitiesTwo Home Health AgenciesTwo Free Standing Surgical Centers (JVs)Two Medical Staffs (currently merging)Ambulatory Care - CamdenFitness Center7,100 employees + 2000 physicians7,752 deliveries8% Operating Margin - #1 in the state of NJSTAR Culture
November 6th, 2006
Virtua Locations
November 6th, 2006
Strategic Imperatives 2007 Continue to improve and sustain patient safety and clinical
quality, through evidence-based practices Improve and sustain patient satisfaction scores with an
increased emphasis on customer service Recognize and continuously develop best people and improve
employee satisfaction, with emphasis on leadership development
Continue implementation of medical staff development plan. Continue facility planning and development of ambulatory
sites and regional medical centers Advance Virtua’s Programs of Excellence development Continue rigor in expense management, revenue
enhancement, and reduced length of stay Begin implementation and integration of digital information
technology and clinical technology
November 6th, 2006
Virtua Health Challenges Today
A formula for a “perfect storm” Aging Work Force
Average age of Nurse = 49 years old Average age of Physician = 51 years old
Impact of Baby Boomer Generation to HealthCare Increasing Competition for Market Share Shorter Length of Stays/Payer Reimbursement Continual Shift to Electronic Work Flow
Processes Malpractice Costs Consumer Expectations Pressure from Government & Industry to Reduce
Costs
November 6th, 2006
Virtua Health Tomorrow
Greenfield Healthcare CampusComprehensive Ambulatory CentersContinued specialization of Marlton
CampusRedesign of Memorial Hospital
CampusDigital Healthcare StrategyPhysician Partnerships and
Recruitment Investment in Best People
November 6th, 2006
What Makes Virtua Different?
We are a Community Based Health System that has deployed the following: Relentless Measurement Rigor and Accountability Programs of Excellence Our Tool Box Partnerships with Industry Our People Our Results
November 6th, 2006
The Virtua STAR: The Backbone to Our Organization
CaringCulture
ExcellentService
Clinical
Quality &
Safety
ResourceStewardship
BestPeople
Outstanding
Patient Experienc
e
November 6th, 2006
Relentless Measurement
Everything we do is based on the 5 points of the STAR
Balanced ScorecardQuarterly Goals and Objectives
ReviewFriday BriefingVarious awards for Quality
November 6th, 2006
Score Card Snap Shot
November 6th, 2006
Quality
Winner of the Quality New Jersey Bronze Governor’s Award for Performance Excellence for 2005 (applied in 2006)
Balanced Score Card: The Star Report Joint Commission Constant ReadinessSustainability of Results Utilizing the
Virtua Tool Box Many of our Virtua Quality Goals exceed
national standardsParticipating in Regional and National
Quality Initiatives
November 6th, 2006
Best People
Incorporation of General Electric Human Resource tools into Virtua Best People Review Goals and Objectives Process Operating Calendar Talent Coaches Ranking of Talent Internal promotion
Annual Employee Opinion Survey
November 6th, 2006
Vitality Curve
“Valued Contributor”
“Top Talent” no more than 30%
“Needs Improvement”
10-15%
November 6th, 2006
Programs of Excellence
Programs of Excellence Women’s and Children’s Neurosciences Healthy Aging Orthopedics Surgery Cardio-vascular Oncology
Program Strategy is Delivered through a Planning Process of S1 and S2
November 6th, 2006
The S1 Components Definition of Core, Emerging and Crossover
Business Units Projected financial performance
Market share Patient inpatient and outpatient volume Revenue & CM projections
Market Dynamics Competitive Analysis Market Share Detail Payor Mix Legislative Impact Technology Impact – Sg 2 Physician Availability Market Intelligence
Technology impact – Sg 2 Physician availability Market intelligence
November 6th, 2006
The S1 Components ContinuedStrategic initiatives
Specific strategies to achieve financial projections clinical quality and safety goals and service focus
Service venue: Inpatient and ambulatory strategy
Medical staff needs: Primary care, specialty care
Marketing strategy Workforce needs Investment requirement
November 6th, 2006
Operating plans and performance evaluation
Initial annual plan including timelines and accountability
Financial impact of planQuarterly assessment of actual
performance against the plan for: inpatient and outpatient volume and financial
performance program and service development and physician
recruitment goals quality and safety and service excellence goals
The S2 Components
November 6th, 2006
Resource Stewardship
Rigor in Expense Management Complemented by the Goals and
Objectives Process Fueled by the Friday Briefing Process Enhanced by our Tool Box Early and rigorous budgeting process Quality saves money
November 6th, 2006
Annual STAR Launch
G&O review & signoffPOE report & Final S1
G&O Review #1
QMM Meeting & celebration QMM
Best People UpdateG&O Review #3EOS
Budget Process
Best People Review
G&O Review #2
January 07
February
April
May
June
September
August
July
November
December
October
Outstanding Patient Experience
Stewardshi
pPatient Safety
Best People
Caring
CultureClin
ical
March
Virtua Values
1st Quarter
2nd Quarter
3rd Quarter4th Quarter
Virtua Health STAR Management System 2007
Resource
Service Excellence
Quality &
January/Feb 08
08 Star Launch07 4Q G&O Report Out
Strategic Imperative update for 2008 budget planning
QMM
POE S2 review & S1 draftQMM
November 6th, 2006
Virtua – GE History Bio – Med contract: 1998 Cultural change Post Merger: 2000 Six Sigma, CAP, Work Out: Oct 2000 Master Black Belts: 2002 ENTERPRISE CONCEPT IS BORN Work Out with GE Leaders: Feb 2003 Site Enterprise Representative: Sept 2003 Leadership and Management Systems: Nov
2003 Technology Assessment and Sg2: July 2004 S1 – S2: Fall 2004 DFSS and Personalized Healthcare: 2005 LEAN: 2006
GE
Virtua
Clinical & OperationalExcellence
Financial Performance Management
Technology Optimization
Strategic Planning
& Business Development
Learning &Leadership
Communication& Public Relations
The Basis for the Agreement
Partnership Today
GE
Virtua
Clinical & OperationalExcellence
Financial Performance Management
co
Technology Optimization
Strategic Planning
& Business Development
Learning &Leadership
Communication& Public Relations
• Greenfield planning• Hospital Workflow• Sg2 relationship• S1 & S2• POE Development
• Leadership and Mgmt Systems• G & Os/Best People • GE CXO site visits• S1 and S2• POE development
• GE Technology Assmt• Digital IDN• PACS• EMR• Exablate (Insightec)• Work Flow Evaluation
• World Health Congress• NBC 10
• Exablate• Women’s Health Tour
• Attaché• Women’s Health Symposium• Lean Symposium
• Six Sigma• DFSS• Lean• Personalized Healthcare
• GE Card Services• GE Capital• Healthcare Financial Services
November 6th, 2006
Partnerships 10 Year Strategic Partnership with General
Electric 3 years into the relationship Full time Enterprise General Manager dedicated to
Virtua Engagement with Jeff Immelt
“Virtua is a think tank of ideas” “In order for our business to continue to grow, our
customers need to be healthy and we want to help them get there”
Virtua does not need to make everything Has created the opportunity to work with
other appropriate industry partners
November 6th, 2006
Info Access + Process Reliability + Efficiency =
Safety, Quality
Paperless
Filmless Wireless
November 6th, 2006
A Very Complex Project…
November 6th, 2006
Information Technology
Partnering with GE on many fronts for this initiative
Creating new roles in Healthcare: Informaticists and Management Engineers
Need a combination of the Virtua Tool Box and great people to undertake this task
Most organizations will underestimate the amount of training that will need to take place over the next couple of years
The Application of Tools at Virtua
November 6th, 2006
Current State:
STAR Commitment
Desired State: STAR Performance
It’s Great to Have a Philosophy . . . But We Need a Strategy !!
The Virtua Tool Box is a part of our strategy
on our journey through the maze
The Virtua Tool Box is a part of our strategy
on our journey through the maze
November 6th, 2006
Usual pattern of process improvement (when improvement takes place!)
Process improvement with CAP and the Control Phase of Six Sigma
The Challenge…..
VIRTUA’S VIRTUA’S Performance Performance Journey Journey Continues…Continues…
WJ: Quality Circles: early - late 1980sMH: Morbidity and Mortality Reviews, Quality Audits
WJ: Quality Assurance: mid 1980’s
MH: Quality Assurance: mid 1970’s to mid 1980’s
WJ: Quality Assessment: late 1980’sMH: Quality Assessment mid to late 80’s (Leadership explores Total Quality Management Concepts with VHA 1988 - 1990)
WJ: Total Quality Management: early 1990s
MH: Total Quality Management 1990 - 1995
WJ: Re-engineering / Patient Centered Care: mid 1990’sMH: Metric Focused Quality Improvement (AQP) / Patient Focused Care: mid 1990’s
Virtua Health: STAR, Six Sigma/CAP/Workout, Becoming a Learning Organization - October 2000
Virtua Health: LEAN, Simulation, Management Engineering November 2003
Virtua Health: Leadership and Management Systems, DFSS-C 2004 - 2005
November 6th, 2006
The Tool Chest
Paths to Change•Strategic Decision
•Operational Issue Requiring a Decision
•“Wisdom of the Group” Problem
•Eliminate Delay/Waste
•Eliminate Defects
•Design Out Defects
Change Acceleration
WorkOut
Lean
Six Sigma
Execute
Design for Six Sigma
November 6th, 2006
Solid tools but….
Quality tool Vague goals No standard metrics Open-ended, unstructured Department-based Focus on product quality
Real results that matter to customers….
Business tool Clear goals/deliverables Clear, consistent metrics Rigorous timeline Business-based Focus on customer
Six Sigma builds on Lessons Learned from prior approaches
TQM Six Sigma
What Makes Six Sigma Different?Adapted with permission from Hamadi Said, US Mint Philadelphia, PA
November 6th, 2006
Financial ImpactOperations Improvement Annual Cost
$-$200,000$400,000$600,000$800,000
$1,000,000$1,200,000$1,400,000
2000 2001 2002 2003 2004 2005 2006
Year
Dol
lars
Operations Improvement Annual Benefits
$-
$1,000,000
$2,000,000
$3,000,000
$4,000,000
2000 2001 2002 2003 2004 2005 2006
Year
Dol
lars
Operations Improvement Net Benefit
$(2,000,000)
$(1,000,000)
$-
$1,000,000
$2,000,000
$3,000,000
$4,000,000
2000 2001 2002 2003 2004 2005 2006
Year
Do
llar
s
Drill Down on the Tools
Change Acceleration Process (CAP)WorkOut
LeanSix Sigma
Change Acceleration Process (CAP)
If we all know change is hard, why does resistance to change keep
sneaking up on us???
November 6th, 2006
When To Use CAP
DecisionsWorkOut
RecommendationsSix Sigma ProjectsAny Time Change is
Desired
November 6th, 2006
WorkOut
1 or 2 DaysTrained CoachesSponsor and Process OwnerSensing Session (Issues,
Participants, Boundaries, Deliverables)
Planned agendaChargeReport OutW W W
November 6th, 2006
CategorizeProblems/Barriers
Ease Implementation
Define the Problem
BrainstormProblems/Barriers
Define “Headers”for Categories
Prioritize Categories
2 10 9 1 6vo
tes
Brainstorm Potential Solutions
AssessPotential Solutions
Pa
y-o
ff
Develop Action Plans
Share Action Plans
Report-Out Action Plans
Kick-Off
Ground Rules, Introductions,
Roles, etc
Mission
What: Who: When: Resources
CategorizeProblems/Barriers
Ease Implementation
Define the Problem
BrainstormProblems/Barriers
Define “Headers”for Categories
Prioritize Categories
2 10 9 1 6vo
tes
Brainstorm Potential Solutions
AssessPotential Solutions
Pa
y-o
ff
Develop Action Plans
Share Action Plans
Report-Out Action Plans
Kick-Off
Ground Rules, Introductions,
Roles, etc
Mission
What: Who: When: ResourcesWhat: Who: When: Resources
What a WorkOut Looks Like….
November 6th, 2006
WorkOut Issues
Ambulatory Surgery Workflow Community Acquired Pneumonia
SOPS Visitor Access to LTC Center FMEA Infant Abduction Rental Equipment Safety Inspections OR Case Cart Accuracy Patient Complaint Process Registration and Billing Accuracy in
Dental Center
Work Out: MedSurg Supply CostsWhat the Team Did … Why They Did It …
Extraordinary financial impact, gratifying cultural change, from two days work (and a year of
implementation!!!)
• Six teams of 8-10 people each met for two days to reduce supply costs by $821,000
Total savings? You decide!WorkOut on Feb 10, 2003
Challenge: $347,000 removed from budget with no plan for achieving
Came in under budget by $121,000
Total hard savings $468,000 by 12/31/03
Projected over spending: $473,000
? Total benefit of $941,000
• Six Sigma project on Supply Cost was terminated – wrong tool!
Teams from OR, Amb Surg, EndoCysto, MedSurg, ICU, ER all worked together
Learned from each other
No “victim” mentality
A true team success for the facility
• Used numerous strategies to communicate costs and waste to peers
• Quantified challenge as per-patient reduction
• Focused team on high volume low cost items
• Spread the awareness, recruited support
November 6th, 2006
What is Lean? Increasing customer value by eliminating waste
throughout the value stream*
* Based on definition in the book Lean Thinking, Womack & Jones, Simon & Schuster
In healthcare, Lean is about shortening the time between the patient entering and leaving
a care facility by eliminating all non-value added time, motion, and steps
We Spend 75-95% of Our Time Doing
Things That Increase Our Costs and Create
No Value for the Customer!
November 6th, 2006
The Lean Process
The continuous movement of products, services and information from end to end through the process
Define value in from the customers perspective and express value in terms of a specific product
Nothing is done by the upstream process until the downstream customer signals the need
The complete elimination of waste so all activities create value for the customer
Map all of the steps…value added & non-value added…that bring a product of service to the customer
2 Map the
Value Stream
3Establish
Flow
4Implement
Pull
5Work to
Perfection
1Specify Value
Using Lean to Improve a Process …Start Time: End Time: Total Cycle Time: 0:00
TAKT 22.65 minObserver: Sylvia Konopka Date: 12/7/04 Mark:
Step Description Time (secs.) Dist.(Ft.) VA VE Wait Travel Inspect NVA-OtherSame Day Surgery Admission
Pre-Surgical Screening (One-Week Prior to Surgery)0 Patient Arrives 0 01 Person at desks notifies Corrinne (screening person) 8 28 12 Corrinne walks to desk and checks off pt on sign in sheet 11 30 1 13 Corrine walks toward patient in waiting area to introduce herself 6 18 14 Corrine introduces herself to patient 1 0 15 Corrinne takes patient back to room 11 30 16 Patient Signs Paperwork 89 0 17 Corrine walks patient to per-surgical screening 84 137 18 Patient waits in pre-surgical surgical screening 577 0 19 Nurse takes patient into exam room B 20 28 1
10 Nurse asks questions/has pt sign papers 1670 0 111 Nurse takes blood pressure 168 0 112 Nurse takes temperature 14 0 113 Nurse draws blood 178 0 114 Nurse completes assessment 350 0 115 Nurse walks to phone to call anesthesia to come down 5 13 116 Nurse calls anesthesia 82 017 Patient waits for anesthesia, respiratory, and house doctor 108 0 118 House doctor arrives to do assessment 0 019 Respiratory arrives 0 020 Respiratory stamps forms, grabs pt bag, and leaves to come back later 128 23 121 Anesthesia enters room 0 022 Anesthesia completes assessment 313 0 123 House doctor completes assessment 596 0 124 Pt waits for respiratory to return 80 0 125 Pt is moved from exam room B to exam room A 17 20 126 Respiratory returns 1045 0 127 Respiratory completes assessment/instructions 109 0 128 Patient leaves building 138 147 1
Patient Wait to Pre-Op Holding29 Arrive in reg and get in line 6 36.6 130 wait in line 65 6 131 talk with ladies at front desk 15 0 132 sit down 13 20 133 wait in line 10 0 134 person at front desk walk to pt 5 0 135 lady at front desk with pt 20 0 136 Walk from Reg to OR Wait Rm Desk 59 172 137 Wait for clerk to show up to OR Wait Rm Desk 360 0 138 Check in at OR desk 0 0 139 OR desk to waiting area 0 73.0 140 Wait to be called to front desk for consult 365 0 141 Walk to front desk 8 73.0 142 Walk to consult room (1 or 2) 5 20.0 143 Clerk walks from desk to consult rm 1 or 2 87 16.0 144 Consult 108 0 145 Pt walks to seat in wait area 10 93.0 146 Clerk walks to desk 0 16.0 147 Wait until staff calls pt for bloodwork (if necc) 0 0 148 Pt walks from wait area to OR desk (if necc) 0 0 1
49 Pt and phlebotomist walk from OR desk to bloodwork area in pre-op room (if necc) 0 0 150 Bloodwork (if necc) 0 0 151 Pt walks from bloodwork area back to waiting area (if necc) 0 0 152 Wait until staff calls pt for pre-op 2767 0 153 Pt gets up 0 0 154 Pt walks from seat to pre-op door 15 30 1
STREAM: Same Day Surgery AdmissionValue Stream Map
1.0 Detailed process observations
2.0 Validated process map
Day of Surgery:
Distance = 4127.6 ft.
Patient
Nurse
3.0 Spaghetti analysis
5.0 Process improvement plan
4.0 Value analysis and improvement opportunity
November 6th, 2006
Lean: Making the Very Best use of the Resources We Have
Only the right work…. Only the right way….
Everywhere.…All of the Time!
November 6th, 2006
Before Kaizen After Kaizen
Operation Problem Actions Taken Results
Kaizen ImpactED physician workspace
Multiple locations for physicians to check for results leads to patient care delays
• Re-Organized physician work area
• Increased visual cues• Consolidated work space• Standardized work roles for US
and physician• Designated area for charts by
status• Piloted Biometric login
• One location for results• Consolidated physician area
for improved workflow access to resources
• Standard process for d/c mgmt
• Better visual cues• Fewer delays with system
November 6th, 2006
Before Kaizen After Kaizen
Operation Problem Actions Taken Results
Kaizen Impact
Fast Track Patient Flow
Fast Track delayed due to acute patient overflow
• Created dedicated Fast Track space• Added 2 acute beds!• Poke yoked beds for Fast Track
patients• 5S rooms to create standard
inventory of supplies• PA dedicated to Fast Track
• Clearer focus on the Fast Track patient and business
• Faster cycle time for Fast Track patients
• Fewer delays• More space for Acute
patients
November 6th, 2006
Before Kaizen After Kaizen
Operation Problem Actions Taken Results
Kaizen Impact
Fast Track Nursing Station
Congested, disorganized workspace
• Remove clutter and clean new area
• Moved DC Instruction printer to PA area
• Added Label printer and fax for rads
• IBEX monitor
• Better access for ED staff to resources
• Improved work area for PA
• Better IBEX status visibility
What measurements will the process owner use to confirm
sustained improvements? What system and structure changes
support sustained gains?
Define
Project Scoping
Operations Plan
Strategic Plan
Control
ImproveAnalyze
Measure
What is the right operational area for a project?
What is the right process result to address? What
does the customer expect? How is the current process
performing?
What are the most important factors driving the process results? What changes will deliver the desired process
result?
How well did the changes improve the process?
Project Conclusion
The DMAIC Process
Six Sigma
Acute Anticoagulation ServicesWhat the Team Did … Why They Did It …
Complex Clinical Processes Require Simplification and Error Prevention!
WBH protocol performance fully characterized
Successful transition to LMWH
Improved Lab-Nursing communication
Bed scales, new pumps, MAR
• Reduced process complexity from 92 to 21 steps
• “Catastrophic” failures were drivers of adverse outcomes
• Variation in approaches was creating opportunities for error
Project Results …
• Transitioned UFH to LMWH for DVT/PE and Acute Coronary
• Mistake-proofed UFH and LMWH administration processes (inc WBH MAR)
• Created SOPs for weighing patients and for communicating critical lab results
Labs were obtained, reported and addressed appropriately in the vast majority of cases
Rare failures were gross deviations from protocols
Simplification and Mistake-proofing are critical to patient safety
Learning's …
Revenue Generation ProjectWhat the Team Did … Why They Did It …
A successful project by any measure - productivity, revenue, sustained impact!
Medicare Length of Stay
• Developed SOP’s for billing carve out items
Agreement with MCOs on a simplified carve out billing documentation
Elimination of many unnecessary steps in billing process
Found and corrected over 22 procedures with carve outs which were not being billed
• Improve consistency of billing process
Year Billed Received
2000 $1,275,445 $498,410
2001 $2,585,151 $2,519,707
2002 $2,053,370 $1,740,604
2003 (YTD 6/03) $1,105,020 $834,316
Total (w Rx) $7,830,944 $6,305,348
• Revised Charge Master
• Restructured IS system for billing carve out items
• More accurate charges available for carve outs
• Eliminate non-value added steps, increase reliability and timeliness
Cardiac Meds: A PRO/CMS Quality Indicators Project
What the Cardiac Meds Team Did …
Why They Did It …
Project started in 7/02. All PRO indicators were achieved for Q4 ‘02. Project closed out in July ’03,
Success is sustained to date!
• Gaged current data collection system
Project requested by physician leadership
Documentation was more of a problem than the actual delivery of care
Major progress in achieving physician support for process improvement (including physicians firmly addressing physician outliers!)
• Improve quality and consistency of data
• Created a cardiac discharge instruction sheet
• “Contained” defects immediately while implementing more sustainable systems and structures to support improvements
• To obtain immediate results to achieve aggressive system targets
• Increase compliance from docs and support accurate data collection
Indicator Results
AMA ASA < 24 hrs >95%
AMI ASA at Discharge >95%
AMI Beta Blocker < 24 hrs
>95%
AMI Beta Blocker at DC >95%
CHF ACE at DC >90%
November 6th, 2006
CAP WorkOut Lean Six Sigma
ProblemI know the answer but I’m going to meet a lot of resistance
I have a rough idea of where we need to go. I want my team to work together to improve the process quickly.
I have to do more, faster with less. I want to be sure my team is as productive as possible
The process is important and it isn’t working. I’m not sure why. I need to understand my process better and pick the right solutions.
Deliverable
- Change management- Dealing with resistance- Maintaining the gains
- Helping those who do the work come up with and own great solutions
- Speed - Efficiency- Productivity- Removing waste
- Meeting customer expectations- Eliminating defects
Catch phrase
“Why are we always surprised by resistance”
“The people who do the work know
it best”
“We need to do more with less…. and faster too!”
“We need to get it really right for our customers!”
Turnaround
< 1 day 1 – 2 days 3.5 - 5 days 6 – 9 months
Facilitator CAP/WorkOut CoachCAP/WorkOut
CoachInformaticist/
Black BeltBlack Belt
Matching the Tool with the Task
Design forSix Sigma
This process is so broken we might as well start from scratch and we have new programs we are just starting – I need to build in my customers expectations
- Meeting customer expectations- Eliminating defects in the design phase of the process
“We need to design this
process correctly before we let our
customers experience it.”
6 – 9 months
Black Belt
Project Selection
November 6th, 2006
First Wave Projects Selection…Boiling the Seven Seas!
Employee RecruitingEmployee RetentionPatient Satisfaction in
Voorhees EDMarlton ORVoorhees ORCHFLessons Learned
What makes a good projectBite-sized projectsMultigenerational plan
November 6th, 2006
Subsequent Project Selection
Portfolio 3:1 Financial Return Non-Financial Projects
Alignment with Strategic Imperatives Operations Choice Deployment as our “Antennae”
MBBs propose to Operations Leadership Executive VP has final decision
November 6th, 2006
Project Selection Lessons Learned“Tripping over dollars”Where the money lives
Bad debt – “discoverable” Charge capture – invisible (and huge!)
Move to integrated planning via Wing-to-Wing Value Stream Mapping and Multi-Generational Planning
We don’t know our processes in sufficient detail to identify our biggest opportunities…..
We don’t know our processes in sufficient detail to identify our biggest opportunities…..
November 6th, 2006
Functions:The Reasons
Customers Seek Us Out
Processes: How we use our
Resources to deliver the Functions
Resources: The People and Things we use to make our
processes work
Sup
port
Depend
ence
What Makes a Health System Work?
AccessEmergent
CareSurgical
CareMedical
CareGuest
ServicesOther
November 6th, 2006
Planning &
Metrics
?
Operations
How Deep Is Our Knowledge?
Functions
Processes
Resources
AccessEmergent
CareSurgical
CareMedical
CareGuest
ServicesOther
November 6th, 2006
POEs & Strate
gy
Process – The
Missing Link
Budget
Where Do We Spend Our Time and Attention?
Access
EmergentCare
SurgicalCare
MedicalCare
GuestServices
Other
November 6th, 2006
POEs & Strate
gy
Process – The
Missing Link
Budget
The Impact of Resource Allocation with Inadequate
Process Knowledge
Access
EmergentCare
SurgicalCare
MedicalCare
GuestServices
Other
Failure of Processe
s
Failure in the Eyes of
the Customer
Wasted Resource
s!
November 6th, 2006
Functions:The Reasons
Customers Seek Us Out
Processes: How we use our
Resources to deliver the Functions
Resources: The People and Things we use to make our
processes work
Sup
port
Depend
ence
Enlightened Project Scoping
AccessEmergent
CareSurgical
CareMedical
CareGuest
ServicesOther
Lean
Six Sigma
WorkOut
November 6th, 2006
Virtua Levels of Training
White Belt: Foundation Team members (500-800)
CAP and WorkOut Coaches (206)Yellow Belt: Leaders Using the Toolkit
(356)Green Belt: Full Training with a “day
job” (56)Black Belt: Our Six Sigma Experts (22)Master Black Belt: Teaching,
Mentoring, and Continuity (5)
November 6th, 2006
Site Visits Leading
Practice Research
Peer to Peer Surveys
Photo Journaling
Technology Roadmaps
From-to Adjacency
High LevelFlow
ARENASimulation
IT Enablers
Evidence Based Design
Patient Experience
Desi
gn
Desi
gn
FutureState
FutureState
TransformationTransformation
DesignIntelligence
Move In
Move In
SafetyChecklists
Use of Tools in Hospital Design/Integration
November 6th, 2006
Use of Critical Pathway Program Output
Ante-partu
m
Post-partu
m
WHMSMed/ Surg
ICU
Tele-metry
NICU
Nursery
PCUPedia-trics
PICU
SPU
Mother/ Baby
L&D
Pts. From ED
Direct Admits
Mapping of patient flow to and from all inpatient units for each service line
November 6th, 2006
Lean Thinking Principles
Lean is all about simplifying processes Identifying which parts of a process add value Enabling care to flow more effectively by
eliminating wasteThe Five Principles
Define what value is to the patient or customer Identify where that value exists in a value stream Make the value steps flow by removing all obstacles Pull the patient along their journey, avoid the push Perfect and strive to standardize and improve
November 6th, 2006
Key Characteristics in Extreme
November 6th, 2006
Surgery
November 6th, 2006
Spaghetti Diagram – Pharmacy Schematic Design II
I.V. Pharmacist
Tech
I.V. Tech
Buyer
Total Miles Walked annually - 1st Shift (within pharmacy)
I.V. Pharmacist
Tech
I.V. Tech Buyer
64
127
124
205
Majority of picking and IV prep
contained in work cell
Drug storage/inventory is accessed often by IV
Tech
Med cart prep located centrally to IV prep and PO prep
November 6th, 2006
Buyer Space Relationship Diagram
Pickstation
Workstation 2
Refrigerator
Workstation 1
Back
Door
Workstation 3
Front
Inve
ntor
y
Room
Back Room
21-42
< 68-17
*Frequencies of movement are per 1st shift observed (6/12)
Buyer travels from to drug/storage inventory room
frequently, therefore adjacency is critical for buyer but not
critical for othersIV Tech, Pharmacist and Tech
have high frequency adjacencies that are within their work cells
Owner High Frequency Task Frequency
Tech Pick station to Tray 34
IV TechWorkstation I to
Inventory 39
IV PharmacistWorkstation to
Computer 30
November 6th, 2006
Comparison of Schematic Designs
Distance traveled annually (miles)
1st ShiftCurrent Design Option I Option II
IV Pharmacist
149 62 64
Tech 124 106 127
IV Tech 172 95 124
Buyer 123 205 205
Total 568 468 520
8'- 6
3/1
6 "
2'-1
0 1/
16"
November 6th, 2006
Leadership Implications
What a Black Belt learns: Who is the customer? What do they want? What is the process that leads yields our
product/service? How often do we disappoint our customer? What factors drive our process
performance (defects)? How to mobilize those who do the work to
improve the process Locking in the gains
And, these competencies/training/development are
delivered at a cost of…..
November 6th, 2006
Financial Impact
Operations Improvement Net Benefit
$(2,000,000)
$(1,000,000)
$-
$1,000,000
$2,000,000
$3,000,000
$4,000,000
2000 2001 2002 2003 2004 2005 2006
Year
Do
llar
s
A Profit!
November 6th, 2006
Leadership Implications
Recommended Educational Outcomes1
Change Management Finance and Reimbursement Populations- based organizational management Information systems and technology Quality improvement Standardization Consumer satisfaction Market and regulatory
strategic management of health services lifelong learning
1 PL Davidson et al. A Framework for Evaluating the Impact of Health Services Management Education The Journal of Health Administration 18:1 1-48 2000
November 6th, 2006
Tool Kit Summary
The right tool for the right taskTransparencyCommon languageHighly teach-ableThe people who do the work fix it bestProgress is easy for leadership to
monitorEveryone becomes an agent for
changeA highly plausible path to success
November 6th, 2006
Physicians and Hospitals:A Unique Business Relationship
Physicians:Drive clinical processesHeavily influence financial
performanceAre generally not employedAre difficult to influenceAre both Customers and
Stakeholders
November 6th, 2006
Physician Perspectives on Process Improvement
“Nothing ever
changes around here”
“Sure, I’ll be there. We’ll meet for months and
nothing will change”
“Didn’t we solve that two years
ago?”
“Administration never
delivers on their
promises”
“A meeting at 2PM!!! Are you
kidding?”“It’s just another Flavor of
the Month”“Admin is great at
saying no to things that will really
help”
“Oh no, not another
“Sticky Note” session - I’m outta here”
November 6th, 2006
Hospital Staff Perspectives on Physician
Involvement
“They only care about getting in
and getting out”
“They don’t have any idea how much work we put in on this”
“All they do is attack the data”
“Can’t someone
make them come to the meetings?”
“Yeah, they no- show then veto the plan!”
“You can’t get a
decision from the
docs” “This is a physician
issue”
November 6th, 2006
How is Six Sigma Different?
Projects start with Customer Requirements Process Average is only half the story
Variation must be evaluated and addressed
Prioritizes interventions based on basis of failures
Ambitious, quantifiable goals (3.4 DPMO) Focus on quantifiable, practical, business-
relevant results Rigorous Control measures assure
sustained benefit
November 6th, 2006
When Physicians Need to Change
Fix hospital “owned” systems first Fix hospital-physician interface
problems next Encourage complaints Improve the physician experience Demonstrate the “physician driven
delta” when it is Number One on the Pareto Chart
Go for the outliers The data better be good!
November 6th, 2006
ResultsNothing else mattersThis will win the docs supportMake them visibleMake them stickCelebrate the docs’ support and
success (don’t underestimate the power of this step!)
November 6th, 2006
What have we learned? Healthcare needs to act more like a
business We are doing that….
Healthcare needs to focus on what they do best
Consumerism will “consume” healthcare Data, data, data
Translates into increased outcomes decreased liability
The Virtua – GE learning has produced great results……