New Zealand

Eastern Health Urology OPD

Fran Brockhus – Assistant Director of Nursing

Project Aim & Plan

Project aim: Reduce decrease the waiting time for Urology Outpatients by 50 %

Project Plan: Develop Value Stream Map Identify Wastes with staff

Current State Value Stream Map

Patient

Sees GP & is referred to Out Patients

Department ( OPD)

Medical Record

ED HMO OPD Nursesring to book in pts in ED currently at back of clinic

check on how many patients in front

Patient calls clerk to make appoint OPD clerk admissions office Patient

told to wait for ref to arriveasks how log till appointment\

referral referral make appointmentappointment received arrive for appointment Admin ready to be seen Seen

generated receivedGP OPD clerk OPD clerk patient Pod clerk Nurses Consultant

ref written clerk - puts in folder 5 mins check pt has UR 5 minsif pt full pt details unknown send to admissions office 10 mins

Pick up appointment card/scrap of paper from bucket 5 mins

seen in rooms by consultant or Registrar 15 mins

faxed to opd NUM sorts outcheck details are current 1-2 weeks if urg

write UR on sheet, input UR next to appointment on computer

look for history & tick off list as ready to be seen

NUM insert into plastic sleeve 1 hour write appoint letter

6- 8 weeks if not

tick off list at front & send history to back 2 mins

if no history ring MR and get history 20 mins

Consultant - triage into urg/non urg 30 mins post to patient 1 day

appt card placed in tub for nurse to collect Need to find it - if not

can take from 1-7 days avg 5 daysring sometimes if urgent

if no card all details written on scrap & placed in bucket

there must be out of the department

wait to be called

av 10 days2 days 5 days 1 day av 49 days 30 mins 20 mins Production 19 days urgent

Lead Time 58 days non urgent30 mins 95 mins 5 mins 12 mins 5 mins 15 mins Processing 2.75 hours

Time

If Fails to arrive for appointment

Consultant assess history to decide action

nurse sends out list marked with FTA 20 minsdocument in history that new appoint made

notified Fta on computer system

histories and list go to clerks

Go back to make appointment process

WWWWW W

REWORK - pt details not checked, letters hand written, histories not made up ahead of time.

,MOTION -of nurses moving from back to front to get pt cards - taken away from patient care

FTA - lead to over booking, delays, unpredictable work load, unnecessary work pulling /storing histories, rework of booking process.

Key Wastes Identified

Motion: nurses moving backwards and forwards as no link between clerical area & patient care area.

Non-standardised work – letters handwritten, details not checked, details not known prior to arrival, history not available

Rework – Failed to Arrive system – over booking, excess history pulling, queuing of patients,

,Reduce Time / MOTION Waste -of nurses moving from back to front to get pt cards - taken away from patient care

Kaizen Blitz Actions:

Showed staff ‘Kaizen Toast’ video and then

Played the’ push pull ‘game with OPD staff

Discussion with staff to select area for Kaizen Blitz–decided to try changes to log in process/ preparation of history on arrival.

Trialled new process with 1 clinic AM/PM to begin with.

5S to improve efficiency in clerical area. Re arrange clerical area to enable better work flow.

Next steps: look at systems/process for getting all histories in correct place prior to clinic start.

Discussion with HIS about processes for history collection

Measured Improvements; Ave. Waiting for history to be sorted reduced from 50munites to 22 minutes. Walking time of nurse per clinic reduced by 250 metes

Patient

Sees GP & is referred to Out Patients

Department ( OPD)

Medical Record

ED HMO OPD Nursesring to book in pts in ED currently at back of clinic

check on how many patients in front

Patient calls clerk to make appoint OPD clerk admissions office OPD clerk Patient

told to wait for ref to arriveasks how log till appointment\

referral referral make appointmentappointment received arrive for appointment Admin ready to be seen Seen

generated receivedGP OPD clerk OPD clerk patient Opd clerk Nurses Consutlant

ref written clerk - puts in folder 5 mins check pt has UR 5 mins Check pt details on arrivallook on screen to see that patient has arrived 5 mins

seen in rooms by consultant or Registrar 15 mins

faxed to opd NUM sorts outcheck details are current 1-2 weeks if urg

Arrive' patient onto computer system

collect history and call patient into room

NUM insert into plastic sleeve 1 hour

get system to print letter with full date

6- 8 weeks if not

if pt full pt details unknown send to admissions office 2 mins

Continue with nursing duties at back of department

Consultant - triage into urg/non urg 30 mins post to patient 1 day

look for history and move to bench ready for nurse

can take from 1-7 days av 5 daysring sometimes if urgent

if no histroy ring MR and get history 10 mins

av 10 days2 days 5 days 1 day av 49 days 12 mins 10 mins Production 19 days

Lead Time 58 days30 mins 95 mins 5 mins 12 mins 5 mins 15 mins Processing 2.75 hours

Time

If Fails to arrive for appointment

Consultant assess history to decide action

nurse sends out list marked with FTA 20 minsdocument in histroy that new appoint made

notifiet Fta on computer system

histories and lsist go to clerks

Go back to make appontment process

WWWWW W

Decrease in time as history is sorted out earliere in the process Previously waiting up to 50 mins, now average time is 22 mins

Decrease in motion . Nurse now stays at the back of the clinic, and collects the history - for patients ready to be seen. Decrease in approx 250metres of walking for the nurses.

Best Outcomes to Date

Setting up the system to mail merge and print all appointments. This has reduced time and error rates. On one of the hand written letters

a patient had a day and month but no year, and arrived a year early for his orthopaedic out patient appointment!

Changing the check in process for patients This was initiated by the clerical staff and provided benefits in waiting

time for patients by 28 minutes and decreased the motion for the nursing staff (decreased distance walked by 250m). They did not have to cross the floor as often. Although this was a small change, it was owned and acted upon by the staff. It was a small step but proved to them that the concepts discussed could work. It was a change that they had control of.

Staff have made the change, They understand why they have done it & are willing to look at other

small changes that they can manage

Outcomes

Used the new process for 4 clinics with very good outcomes – only a few small issues.

Decreased times nurse has to cross the floor ( av of 23 pts x 10 metres across Department). Nurses were happy to be ale to stay in Pt Care area – felt less busy.

Next Steps:

Look at systems/process for getting all histories in correct place prior to clinic start.

Discussion with HIS about processes for history collection

Processes for unexpected arrivals – similar to process used in ED

Next Steps – still to be done

The phone survey showed that most people did not arrive because they forgot, or had made other arrangements to be seen. This has not yet been followed up.

Analysis of the booking process showed that the batch booking was severely overbooked and there was no way to avoid waits. This also needs further follow up, and discussion, as reducing the failure to arrives will only make the clinics more overbooked and frantic, if the booking process is not looked at as well.

Ideas to be Tested Trial calling patients prior to day of appointment to remind them and confirm

appointment. Review appointment schedule and refill any vacant positions by phone –

avoiding overbooking Arrange to get histories for patients closer to time of appointment. Look into other systems for reminding patients eg SMS.

Personal Reflections on Lean The opportunity to learn the principles of Lean Management was a great opportunity, and has given me skills that I can apply in my

everyday work. Many of the concepts make good sense, even if not applied in a formal ‘lean project’.

Lean has given me some valuable thinking and process tools to use in planning and implementing change.

It was great to use the tools we were taught, eg the paperclip game, and then discuss with the staff how the concepts really applied to their issues. They were able to understand and grasp the different concepts that we were discussing. I felt that I had enough material and support to teach something that was still a new concept to me, and do it well. We were given a lot of support.

The weekly teleconferences were good for keeping me on track. It gave me a deadline to work to so that there was some steady progress in my project. The

It is hard to start on your own, and in an area where you are coming in as an outsider. Although I could see some of the issues clearly with fresh eyes, I was just another outsider coming in and telling them how to do things better.

One of the best Ah ha moments for me was when I realised that the staff in OPD needed to make the change not me. I needed to listen to them and not let my project get in the way of a small real step for them in reducing waste.

Trying to do a project as an extra to my work was both a positive and a negative. I came into the OPD with fresh eyes, was non-threatening to the staff and had to really work with the staff to get them to work with me and trust me.

As it was outside my normal work responsibilities, it stretched my work time and often left me feeling that I was not doing anything properly. In hindsight, I could perhaps have chosen a project from within one of my areas of responsibility.

It is hard to continue on your own. There have been several discussions recently about process issues, and I have suggested that some ‘Lean ‘thinking might help here; perhaps even some process mapping to help make the processes and waits more obvious. I was told ‘it had been done before’, and I felt that some frustration that there is learning and tools that we could use in the organisation, but not a mass of people with the understanding to use the lean tools. It can be hard feeling like you a ‘lean ranger’. I am not sure how to get the next project started, but am keen to go over what I have learnt and use the lean thinking again.