Perfecting Patient Care: Applying the Industrial Model in … · 2008-12-23 · Perfecting Patient Care: Applying the Industrial Model in Healthcare (004-0074 ) Debra Thompson, Pittsburgh

Perfecting Patient Care: Applying the Industrial Model in Healthcare

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Debra Thompson, Pittsburgh Regional Healthcare Initiative

Kristina Hahn, Children’s Hospital of Pittsburgh

Draft

Abstract

The healthcare industry needs radical transformation to ensure a healthy future. This presentation will describe the work of the Pittsburgh region to apply the principles of the Toyota-based Perfecting Patient Care System™ to healthcare. This system offers a unique approach to improving patient care through continuous problem-solving on the front line of care that strives to close the gap between current practice and ideal care. Using PPC, each person learns from each improvement and change accelerates into “rapid-cycle problem-solving.” The model, its application and outcomes will be discussed along with a specific example of its use to improve access to diagnostic services in a pediatric population.

Introduction

The landmark 1999 Institute of Medicine (IOM) Report, To Err is Human: Building a Safer Health Systemi, rocked the nation with its assertion that medical errors kill as many as 98,000 Americans annually. Medical error, it said, represented the third leading cause of death in the nation. That this level of care should consume 15% of the country’s gross domestic product defied understanding. Later studies would confirm that American patients receive recommended healthcare services for their conditions only about half the time.

In addition to rising costs and concerns about safety and quality of care, a shortage of providers continues to strain the nation’s healthcare system. The patient safety movement has galvanized consumers, providers and payors to reexamine how care is provided. The most recent IOM report, Building a Better Delivery System: A New Engineering/Health Care Partnership,ii recommends that system engineering be used to improve the efficacy, quality, safety and patient-centeredness of the healthcare delivery system.

The Pittsburgh Regional Healthcare Initiative (PRHI) has been a pioneer in this arena by developing the Perfecting Patient Care System (PPC) ™ based on the Toyota Production System. This system creates the capacity for rapid, continuous learning and improvement while simultaneously achieving the highest quality, lowest cost and shortest delivery time for care.

This paper will discuss the background of PRHI and the tenets of PPC. It will also provide a case study of the successful application of PPC in an outpatient pediatric setting.

Pittsburgh Regional Healthcare Initiative History

In 1997, the small, nonprofit Pittsburgh Regional Healthcare Initiative (PRHI) convened medical and business leaders, insurers, and others to discuss ways of making health care delivery in Southwestern Pennsylvania safer, better, and less expensive. The group focused its efforts not on cost-cutting, but on quality. They began by calling for the elimination of hospital-acquired infections and medication errors, and for best practices to be applied 100% of the time. Transforming healthcare through improved quality, they believed, would lead to unimagined improvements in patient outcomes and, ultimately,

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vastly reduced cost. PRHI partners quietly began a bold experiment. They began to apply principles borrowed from engineering and industry to eliminate waste and error from healthcare systems. Adapted from the Toyota Production System, the Perfecting Patient Care System became the centerpiece of the community effort. Aiming for Zero

Of all the hopeful ideas to come out of PRHI initially, none provoked more controversy than the goal of “zero” errors. Many professionals believed that healthcare-acquired infections, for example, could never be eliminated because they were an occasional but inevitable part of complicated medical care.

Over time, the conversation began to shift. The goal of “zero” began to be viewed more from the patient’s perspective. To the patient, how many errors are allowable? Who would volunteer to be harmed or have harm inflicted on one of their family members in such a lottery? And yet, if the only acceptable number of errors is, indeed, zero, how can fallible human beings working within fallible systems begin to approach that goal? The question evolved from the accusatory, “Why don’t you?” to the curious, “Why can’t we?” Instead of blaming individuals who made all-too-human mistakes, why couldn’t the underlying system be redesigned to respond to every worker, making it nearly impossible for mistakes to occur? And shouldn’t mistakes be disclosed, so that their causes could be examined and addressed?

These questions formed the basis of PRHI’s PPC system, which set about to improve care at the bedside, one encounter at a time.

Today—nearly a decade after the idea evolved among PRHI partners—the idea of zero as the only acceptable goal is no longer controversial. The idea that systems, not people, must be transformed—one by one—is no longer controversial. Terms like “zero goals,” “perfect care,” “systems thinking” and “transparency,” which have been part of the PRHI lexicon for nearly a decade, are now integrated throughout the burgeoning quality improvement movement. Portfolio of Projects

Since its inception, PRHI and its partners have boldly tackled some of the most damaging, costly and seemingly intractable problems in health care. The healthcare community has come to rely upon PRHI as a neutral place where practitioners from across the region can discuss and share ideas about how to improve care, and where they can turn for information and education on systems improvement—namely, PPC.

The current portfolio includes: • Hospital-acquired infections—central line-associated bloodstream infections;

ventilator-associated pneumonia; antibiotic-resistant bacteria.

• Chronic care—particularly diabetes in the primary care setting, where the most potential exists to reduce harm to patients.

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• Cardiac surgery—examining who recovers more quickly following coronary artery bypass graft surgery, and looking at results of a unique, community-wide registry of shared data.

• Long-term care—the fastest growing segment in health care, in terms of number of people, dollars and problems.

• Errors in pathology—improving not only the skill of pathologists, but the accuracy of all processes in the chain.

PRHI focuses its organizational resources in areas where there is broad interest and a chance for transformation. All of PRHI’s projects are designed to produce replicable models for transforming care throughout Pennsylvania and elsewhere in the country. At the same time, the transformations in care achieved through these projects are expected to lead to dramatic reductions in cost and to the kinds of cultural changes in healthcare that will help the industry attract and retain workers amid serious labor shortages. PRHI Creates Perfecting Patient Care™

Starting in 2001, PRHI helped Pittsburgh hospital partners to begin refining and adapting Toyota-based principles to improve healthcare processes—in essence, making it easier for workers to do the right thing and harder to do the wrong thing. Rapid, frequent problem-solving by frontline workers, with the full backing of leaders throughout the organization, is the cornerstone of improvement. The resulting system is called Perfecting Patient Care (PPC), and it is the distinguishing feature of the initiative. Other regional and national efforts have promoted data collection and collaboration among “stakeholders,” but none has developed an actual on-the-ground method to propel dramatic improvement.

When in 2005, the IOM teamed with the National Academy of Engineering to produce a Building a Better Delivery System: A New Engineering/Health Care Partnership,iii calling for the application of engineering principles to health care, PRHI was in full support. In fact, PRHI partners in Southwestern Pennsylvania had been doing so for four years.

PRHI developed an extensive and exclusive curriculum to teach PPC to health care workers: to date, over 1500 people from Pittsburgh and beyond have received some form of this training. The PPC curriculum and on-site implementation were national forerunners in the movement to bring engineering disciplines to clinical practice. Clinical results with PPC

PPC been used successfully to streamline administrative and support processes in healthcare facilities across Southwestern Pennsylvania. Improvements include streamlined equipment supply lines at the VA Pittsburgh Healthcare System, organization of laboratory supplies at UPMC Shadyside, improved timeliness of diabetes care at the UPMC Lawrenceville Family Health Center, and improved access to appointments at the Child Development Unit at Children’s Hospital of Pittsburgh of UPMC.

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PRHI partners have also applied PPC clinically with success: • At Allegheny General Hospital, PPC principles were applied in two intensive care

units to reduce the rate of central line-associated bloodstream infections. For FY 2004-2005, the rate dropped from 49 to 6, and ventilator-associated pneumonias dropped 49 to 8. Work continues to 1) eliminate variation and educate staff on the principles of PPC, 2) spread the work to two other devastating infections, ventilator-associated pneumonia and an antibiotic-resistant strain called methicillin resistant Staphylococcus aureus or MRSA; and 3) document massive cost savings.

• Starting in 2001 at the VA Pittsburgh Healthcare System, in partnership with the Centers for Disease Control and Prevention (CDC), PPC principles were adopted, starting in just one unit to reduce MRSA. Dozens of small system improvements accrued over time, resulting in a greater than 85% reduction in MRSA—and other infection as well—on the test unit. Infection rates continue to decline. PPC has come to be viewed as a replicable model for transforming care, and may be taken nationwide throughout the VA.

• Across the VA system, other PPC improvements were adopted. For example, compliance with hand hygiene increased, medication was delivered on time 99% of the time, information at shift change was more complete and delivered in a fraction of the time, and clean, appropriate wheelchairs were always supplied within minutes—not just on that unit, but eventually throughout the massive three-hospital system.

• In concert with the VA, PRHI created a type of “How To” manual, entitled the Program for Getting to Zero on MRSA for the VA Healthcare System. The Program, under constant review and revision, is posted on the PRHI website for any institution to use and copy.

• At UPMC Shadyside and affiliated hospitals, the pathology department has improved the quality of Pap smears, increased accuracy of results, and reduced by half the need for retests.

The Business Case Early critics dismissed PRHI’s call for quality improvement as too expensive for

cash-strapped hospitals to pursue. Only a focus on cost-saving measures, they reasoned, such as reducing length of stay, could make an impact on medical costs.

From the beginning, PRHI posited the then-revolutionary notion that “Quality is the Business Case.” Business leaders involved with PRHI agreed that, in principle at least, it was always cheaper to do things right the first time, and that waste, inefficiency, and harm to patients had to be extremely expensive. Hospital partners who had created learning laboratories to apply PPC were patient: they were willing to wait to see whether doing the right thing in the right way paid off financially. Their patience has been rewarded.

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Dr. Richard Shannon, Chairman of the Department of Medicine at Allegheny General Hospital, applied PPC in two intensive care units. He then painstakingly went through complicated hospital documentation and billing for each patient who had contracted an infection. What he discovered turned conventional wisdom upside down: the hospital made a profit by averting hospital-acquired infections. His economic analysis (actual cost minus payment) revealed that AGH lost an average of $26,839 on every central line-associated bloodstream infection and $24,435 on every ventilator-associated pneumonia. The case for preventing hospital-acquired infection is now financially compelling as well. Influencing policy

The Pennsylvania Health Care Cost Containment Council (PHC4), in partnership with the Jewish Healthcare Foundation, is funding demonstration projects in six hospitals across the state. The goal is to determine whether the AGH experience, including financial results, can be replicated and translated to other types of infections. The hospitals have agreed to report back to PHC4 on the actual treatment and costs for hospital-acquired infections.

In a related policy decision, beginning in 2006, PHC4 began requiring Pennsylvania hospitals to report all hospital-acquired infections using CDC’s 13 body-site categories, e.g., urinary tract, surgical site, pneumonia, bloodstream, bone and joint, central nervous system, cardiovascular, gastrointestinal, lower respiratory tract, reproductive tract, skin and soft tissue, and systemic. The reporting mechanism continues to undergo refinement, but hospitals across the Commonwealth are examining their infection rates as never before.

The Pennsylvania Patient Safety Authority (PSA) began in 2004 to require mandatory reporting of errors and near-misses in hospitals, birthing centers and ambulatory surgical facilities. PRHI was consulted as a regional resource as the PSA program began. Gaining Traction

As PPC experiments continue, PRHI learns more about its implementation. Where entire organizations are aligned and committed to improvement, not merely pressed by an outside entity, real change can occur.

To act on this knowledge, PRHI sought to find the most committed doctors and nurses—those with the power to align incentives and work. Backed by the Jewish Healthcare Foundation, PRHI created the Physician Champion and Nurse Navigator programs. The Foundation awarded a stipend, training in PPC methods and access to an individual on-site PPC coaching as needed. Eight Physician Champions and 15 Nurse Navigators are spearheading areas within the PRHI portfolio. Each has committed to sharing what they are learning with one another and the community at large.

Children’s Hospital: an Early Case Study in PPC

An early PPC project, led by a “physician champion,” took place at the Child Development Unit (CDU) of Children's Hospital of Pittsburgh of UPMC. This urban pediatric hospital, among the nation’s highest ranking pediatric facilities, is Western

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Pennsylvania’s only hospital dedicated to the health care of children. Children’s serves a broad pediatric population from across the region, the nation and the world.

The CDU is a specialty outpatient service that provides diagnostic evaluations of children demonstrating developmental and/or behavioral differences. The staff includes professionals from various disciplines, including developmental/behavioral pediatrics, psychology, social work, and advanced practice nursing. Common presenting concerns among the patient population include developmental delays, autistic spectrum disorders, attention difficulties, behavioral disorders, school difficulties, genetic disorders, and developmental and behavioral problems related to medical conditions such as prematurity and neurological impairment. The CDU provides family-centered diagnostic evaluations and referrals for appropriate treatment and intervention services. Specialty long-term supportive care is also available for subsets of the CDU patient population, notably children with Down’s Syndrome and Fragile X syndrome.

In 2004 the larger University of Pittsburgh Medical Center (UPMC) health system, of which Children’s Hospital of Pittsburgh is a subsidiary, began to closely examine access to services within the health system. New standards were implemented to improve the timeliness of new patient visits. The ideal of offering an appointment within 10 days of the patient’s request was established by hospital administration, and all out-patient departments were challenged to meet this goal. The CDU, historically plagued by long waiting lists that, at times, exceeded five months for a new patient visit, was particularly challenged by the health system’s initiative.

The timing of the improved access challenge coincided with the arrival of a new medical director for the CDU, Dr. Robert Noll. He was particularly motivated to improve patient care services. Upon learning of the PRHI’s endeavors to improve patient care through PPC’s rapid, frequent problem solving involving work redesign by front line workers, Dr. Noll, CDU faculty and staff members began to explore the possibility of implementing the PPC system to address problems of long wait lists for CDU services. It was determined by both PRHI and CDU administration and staff members that applying the PPC model to the CDU challenges with access was promising. Hospital administration was supportive of the partnership, and planning for implementation began in the spring of 2004. This endeavor was supported by a grant from the Jewish Healthcare Foundation, of which PRHI is a supporting organization.

Motivation

The ultimate motivation for implementing PPC in the CDU was to improve patient care. Some may wonder how the timeliness of an appointment affects the quality of patient care. After all, the problem of long wait times for specialty appointments is not unique to the CDU, but rather is a phenomenon to which many consumers of health care services have grown accustomed. Imagine, though, for a moment that you are a parent of a young child who is demonstrating delays with language and social development, and is exhibiting some challenging behaviors. You first begin to notice these issues around the time your child is nearly 2 years old. You mention your concerns to your child’s pediatrician at that time, who advises that your child’s behaviors and developmental

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trajectory are not particularly atypical. Everything is probably fine. Wait until the next well child visit and the doctor will reassess the concerns at that time. Several months go by and you continue to have the same concerns. When you observe your child around other children of the same age, something seems different. You then follow up with your child’s pediatrician who refers your child for a diagnostic evaluation with a developmental specialist. You are anxious, but in some ways relieved that you are finally going to get some answers. You call to schedule an appointment, and you are told that your child cannot be seen for several months. You are devastated.

Putting ourselves in the shoes of our patients and their families provided motivation to address the problem of access to diagnostic services. Beyond the empathic response, though, we also know that the research demonstrates that for children with developmental disabilities early intervention improves outcomes. However, early intervention depends upon early and accurate diagnosisiv. There is evidence to suggest that beginning intervention early, particularly in young children with autistic spectrum disorders, is associated with improvements in language, IQ and behavior. Furthermore, early intervention should be provided at the earliest age possible since it aids children in developing functional communication systems before nonproductive or interfering behaviors emerge v(Kabot, Masi and Segal, 2003). Accurately identifying developmental disabilities and providing effective early intervention services is a complex challenge with which many complex systems, including health care, education, and mental health, are faced. Ideally, children at risk for developmental and behavioral disorders need to be identified early by their families, primary care providers, and other community practitioners. Early referral then needs to be made to qualified developmental specialists who are accurately and promptly able to diagnosis the disorders and refer for appropriate treatment services. Treatment services, then, need to be of high quality and specific to building upon an individual child’s strengths to address developmental and behavioral deficits.

Addressing the many challenges of ensuring early and accurate identification, referral and diagnosis along with prompt and early intervention clearly encompasses more than the scope of practice of the CDU. However, the faculty and staff of the CDU embarked upon a mission to improve their piece of this complicated puzzle, specifically the process of accessing the diagnostic services offered by the CDU. Access had been a long-standing problem in the CDU, its complexity daunting. PPC™ offered a system using simple rules and concepts to engage leadership and front line staff in rapid-cycle improvements always striving toward an ideal state. The CDU had a clear vision on the desired outcome—timely appointments. What was needed was a methodology for implementation. Therefore the CDU, led by Dr. Noll, decided to see whether using PPC could equip the staff to solve the problem in more manageable increments to achieve the ideal state of an appointment within 10 days of request.

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Literature Review The basis of PPC, which PRHI adapted for use in health care, is the industrial model,

the Toyota Production System. People are not cars: however, the methods for perfecting complex practices are highly transferable among disciplines.

The Toyota Motor Corporation is known throughout the automotive industry for the highest productivity with the lowest defect rate and costvi. In the 2005 JD Powers Report, Toyota Motor Corporation earned 10 of the top model segment awards.vii Toyota Manufacturing has not had an unprofitable year since 1952, and the 2005 President’s message reports the best fiscal results ever. viii With its global production target of 9.06 million vehicles for 2006, analysts expect Toyota to soon surpass General Motors as the number one automaker in the worldix.

According to Toyota their system was influenced by a need to compete with large volume automobile manufacturers in price, quality and availability to satisfy customer needs while producing in small quantities with limited capital expenditures. Four elements form their operational philosophy: 1) Because the customer is of primary importance, no defect will be passed onto the

customer; the customer will determine the price; and every order will be filled correctly, immediately.

2) Employees make the most valuable contribution and have limitless capacity to grow and learn. In the words of a trainer from the Toyota Supply and Support Center, “Without people we cannot implement or produce a product.”x

3) Kaizen, or the continuous effort to close the gap between current practice and perfection. The “ideal” is the product with no defects, produced without waste of effort or material, one at a time, on demandxi. Kaizen is the bridge between what is and what could be.

4) Look to the place where the work occurs, the “shop floor” (not the far-removed meeting room) to find ways to optimize each worker’s contribution and eliminate waste.xii Taiichi Ohno, who codified the Toyota Production System, defines waste as overproduction, waiting, unnecessary movement, incorrect processing, excess inventory, and defects. Author Jeffery Liker, an expert on Japanese Production Systems and a professor at the University of Michigan, adds unused employee creativity to the list.xiii Because conditions on the shop floor are constantly changing, and because staff input on the shop floor is so valuable, managers make a point of listening and acting upon what they learn and in doing so, create a culture of organizational excellence. Liker (2004) expands on Ohno’s description of the Toyota Production System with

his 4 P’s: Philosophy (long-term thinking); Process (elimination of waste); People and Partners (respect, challenge and encourage their growth); and Problem-solving (continuous improvement and learning). In support of these objectives, Liker advances 14 management principles: 1) Base management decisions on a long-term philosophy that emphasizes the value of

people and process improvement, even at the expense of short-term financial goals.

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2) Create continuous flow to eliminate wait time and ensure that all work is pertinent. Continuous flow also ensures that problems become immediately visible and can quickly be addressed.

3) Produce only what is needed, exactly when it is needed in response from a “pull” or request of the downstream customer. This concept reduces overproduction and problems related to inventory.

4) Level the workload to eliminate the overburden to people and equipment. 5) Pass no problems or defects along. Stop and fix the problem. The culture applauds the

revelation of problems, because only those that are visible can be fixed. 6) Standardize tasks to make the work more efficient and improve work flow, but also to

make problems more immediately apparent. Empower employees to fix problems. 7) Use visual indicators in the work. From the poster to the post-it note, visual signals

provide powerful pieces of information about the conduct of work. 8) Make the machine work for the employee, not vice-versa. For example, as modern

electrical plugs and outlets make it nearly impossible to plug in a device incorrectly. The machinery provides an automatic cue for the user.

9) Use only reliable, thoroughly tested technology that serves your people and processes.

10) Develop leaders professionally. 11) Develop workers professionally. 12) Respect your network. Make sure leaders use the principles in work every day and

recognize the inherent genius of each and every worker. 13) Expand the principles to partners and suppliers. 14) Create an organization of continuous problem-solving and learning. Go and see the

work as it is done; come to a thorough understanding; make decisions slowly by consensus; thoroughly consider all options; then implement rapidly. Improve continuously and share what is learned from each improvement.xiv Translating the principles of the Toyota Production System for application beyond the

automobile industry took Harvard business professors Kent Bowen and Steve Spear four years of observing 40 different plants in the US, Europe and Japan. They concluded that the key to understanding Toyota’s success rests in recognizing that it transforms a pool of employees into a community of scientists—a distinct departure from trial and error. To create change, specifications are defined; the hypothesis is tested; and data determine whether the change really improves the current state. The tacit knowledge underlying the Toyota Production System is described in four “Rules in Use,” included in Table 1 (Spear & Bowen, 1999).xv These four deceptively simple rules provide a powerful system for problem solving at the point of care. And problems solved at the point of care often provide a basis for system-wide changes.

Spear and Bowen defined the “Ideal” as meeting customer need on demand, without waste or defect, immediately, one at a time, at the lowest cost. But in meeting customer need, employees must work in a safe environment. Safety is spelled out as physical, professional and emotional safety. This three-dimensional commitment to safety keeps workers satisfied and participating. Physical safety for all workers is paramount and

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obvious. Professional safety is the covenant between worker and employer that says workers will not lose their jobs if a suggested improvement results in the need for fewer workers. Emotional safety allows a worker to speak out without fear of reprisal when problems are identified and solutions sought. All workers at Toyota are covered by three-dimensional safety—production employees, managers, accountants, and suppliers.

PPC, the Toyota-based healthcare adaptation, allows the people doing the work to become involved in improving their own work to achieve the “Ideal” in patient care 100% of the time. The goal of the “experts”, the people doing the work, is to meet patient’s needs while using carefully defined principles for problem-solving along the way. In time, PPC leads frontline workers to conduct rapid-cycle improvements that continuously and incrementally close the gap between current practice and the defined ideal.

In 2001, the Institute of Medicine’s report, Crossing the Quality Chasm, posited that the principles of complexity science could be applied to the design of effective delivery systems of the future.xvi PPC strives toward the key elements the report describes for improving health care systems: creating conditions in which the system can evolve over time, providing simple rules and minimum specifications, setting forth a clear vision and creating a wide space for natural creativity to emerge from local actions within the systemxvii. The remainder of the paper will discuss how this model was applied at Children’s Hospital of Pittsburgh

Research Question

Achieving appointment times for new patients within the recommended 10-day window would be complicated for the CDU. The PPC approach relies upon the people who perform work to redesign their work to bring about continuous improvement. Implementing PPC requires the selection of a team leader from within the staff to coordinate the disciplined work of rapid-cycle improvement. The team leader’s role included facilitating problem solving with the staff in real time, teaching the principles of PPC, and coordinating data collection and analysis. Helping the team leader was an on-site PPC coach provided by PRHI.

The PPC coach interviewed all faculty, clinical and support staff to gather data about what they thought was working well with the CDU, and to discover opportunities for improvement. It became obvious that all faculty and staff members were committed to providing the highest quality of care to children and their families, and job satisfaction was derived from being successful at doing so. The CDU enjoys consistently positive patient satisfaction ratings among patients served.

The interviews revealed that the question of timeliness of appointments was not just an institutional goal: it also proved to be an area of staff frustration. Sources of frustration for many staff members included not having materials needed to provide patient care where and when needed, and not being able to provide services in a timely manner. Of particular concern for many staff members was the lengthy wait for an appointment for preschool-aged children.

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While a system had been in place for some time for infants and toddlers to be seen more rapidly due to their young age, the nature of common presenting concerns, and increased need for early identification, preschool-age children were waiting several months for assessment. While school age children were also waiting as long for initial evaluations, and the staff was troubled by this as well, preschool age children were deemed to be a priority for improving timeliness of an appointment for several key reasons. First, diagnostic services for young children in western Pennsylvania area are limited, particularly in comparison to the range of services available for older children. Second, school age children with emerging developmental and behavioral difficulties are more likely to be identified earlier because they are more often involved in school and other community activities where teachers and other professionals may identify symptoms and refer for evaluation. Third, as previously discussed, early identification and intervention are associated with positive outcomes, thus identifying children in their toddler and preschool years became a priority for the CDU.

To more specifically define the research question and guide improvement efforts the PPC principle of understanding the current condition was employed. A thorough data analysis, including direct observation of activities and pathways, retrospective review and real-time data collection were performed. The analysis focused upon all components of patient flow through intake, scheduling, registration, and the diagnostic assessment. Listed below is graphic representation of the observations

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Through the observations and data analysis several key factors became obvious and

revealed opportunities for improvement using PPC. For example, it became evident that there were several aspects of the intake and scheduling processes that affected the wait time until the initial appointment. The assessment of the current condition of the intake process revealed that parents called the intake telephone number and were instructed to leave a voice mail message. The call was then returned by an intake coordinator who completed a clinical interview with the caller. The caller was then instructed to complete parent and teacher questionnaires and return them to the CDU. Once received, the intake

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staff reviewed the questionnaire information, some of which was duplicated in the intake interview, and triaged the patient to the appropriate CDU clinical provider. Intake then sent a letter to the parent advising to contact the CDU scheduling secretary to schedule an appointment. Once the parent contacted the scheduling secretary, an appointment was scheduled.

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The chart below summarizes the average cycle time for each of the steps in the intake process:

ACTIVITY CYCLE TIME

(number of days)

Days for Intake and Family to connect via phone 1.83 Date of intake to date forms are received back from

family 26 Date parent forms received to date scheduling letter

sent 2 Date scheduling letter sent to date appointment is

scheduled 11 Date appointment is scheduled to date child is seen for

evaluation 69 TOTAL 110

Thus, the unit discovered that the overall wait for an initial appointment was 110 days. Understanding the current condition then guided the staff to develop methods of process improvement. The retrospective data analysis further revealed that the demand for appointments surpassed their availability. The following graph depicts the running demand for appointments and the capacity.

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Moving 30-Business Day Appointment Demand

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UPMC Children's Hospital Child Development Unit: Appointment Demand versus Capacity Available

(2/13/03 - 1/13/05)

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Observation of patient visits revealed that clinical providers needed to leave the evaluation room frequently to obtain supplies for the assessment and patient education, detracting from face-to-face clinical interaction with patients and families. The system for reordering testing supplies and patient education materials was impaired, and this instability resulted in frequent stock-outs of needed materials, and in wasted time when staff went looking for supplies. The lack of availability of these materials directly affected the efficiency, and in some cases, the quality of an evaluation.

Compounding the problem of already-unstable systems was a move to new, smaller clinical space that occurred at the same time that PPC implementation was beginning. It quickly became obvious that before efforts could begin on evaluating our fundamental research question and standardizing and removing wasteful work from the intake and scheduling processes, stability of supply systems in the clinic area needed to be achieved. Thus, a kanban system, a tool adopted from Toyota Production System, was implemented for reordering testing supplies and patient education materials. Evaluation rooms were also stocked with common materials necessary for an evaluation, significantly reducing the frequency with which clinical providers interrupted an evaluation to obtain needed supplies.

Research Methods As the work environment and supply system stabilized, work began on evaluating

methods of intervention to improve intake and scheduling. Relying upon input of the intake coordinators, schedulers, and other key staff members it was determined that there were several ways in which work could be designed to reduce wait time for appointments. Evaluating the first steps of intake and scheduling—specifically, how telephone calls from parents were received and responded to—a decision was made to begin to answer telephone calls live, rather than allowing them to go to voice mail. Although this may appear to be a simple change, it was actually complex, because it significantly affected the pace of and way in which work had been performed.

The first step in the experiment of real-time phone call answering involved eliminating the 24-hour backlog of calls. To do this, the team leader assisted the intake coordinators in returning all telephone calls, a process that required 1 ½ days. Once completed, the intake coordinators began to answer calls live. Calls that the intake coordinators were unable to answer were answered by the team leader.

The next step in intake was to mail out parent and teacher questionnaires as a condition of scheduling appointments. The team designed an experiment that simply eliminated this step. This was thought to be feasible because the questionnaires duplicated much of the information from the intake interview. Furthermore, the intake staff was confident they could accurately triage patients upon completion of the intake interview without reviewing questionnaires. Staff continued to emphasize the importance of returning the questionnaires before the assessment, as they remain essential components of the diagnostic evaluation. However, questionnaires would not need to be returned in order for a family to be given an appointment.

Because demand consistently exceeded capacity, it was projected that changing this intake process for all patients would quickly overwhelm the system, and potentially

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worsen the access dilemma. Thus, consensus was reached among staff to begin the experiment with preschoolers only. This approach was further refined to a smaller subset of preschoolers, specifically 2-year-olds, in effort to allow for a manageable change to the intake system that did not carry significant risk of overwhelming the department capacity for new visits.

Another necessary component of the experiment was to redistribute case assignment by dedicating a greater number of new patient appointments specifically to the targeted age group. The clinical staff decided that four clinicians, whose age range of patients had, until this point, included both preschool and school-aged children, would focus solely on evaluating the preschool-aged children. The medical staff, whose availability was greater than that of the psychology staff at the time of the experiment implementation, then broadened their range of assessment to absorb a subset of school-age children who previously had been assigned to the psychology staff. This redistribution of case assignment was possible since the medical staff had the training and expertise necessary for providing assessments to this subset of school-aged patients. Once the case reassignments were completed, staff began the experiment of scheduling 2-year-olds at the time of intake.

The monitoring of key data was essential to evaluating the success of the experiment. Specifically, the rate of failed appointments and the rate of questionnaire return prior to the appointment were tracked closely. The hypothesis of the staff was that the failed appointment rate would increase for two primary reasons. First, 24% of parents of preschool-aged children did not return questionnaires and schedule an appointment. Now, 100% of referrals would be scheduled for an appointment. Second, the belief had been held in the department for some time that families who followed through with the process of completing questionnaires as a condition of scheduling were more likely to show up for scheduled appointments than families who did not follow through. It was therefore important to track the rate of return of parent and teacher questionnaires prior to the appointment. It was hypothesized that the rate would decrease as the new scheduling system was implemented. This was concerning because not having the completed questionnaires by the time of the visit was projected to have a negative effect upon the efficiency and accuracy of the evaluation. Tracking these data as close in real-time as possible would allow for the revelation of problems and implementation of countermeasures.

By scheduling the subset of preschoolers at the time of intake, several steps in the intake and scheduling processes were naturally eliminated. Intake staff no longer needed to review questionnaires to triage patients; scheduling letters no longer needed to be sent; and families no longer needed to call the scheduler. As the experiment proceeded several countermeasures were put into place to allow for continuous improvement of the new intake and scheduling process. For example, the initial implementation involved the intake coordinator completing the clinical interview then transferring the caller to the scheduler who then scheduled the appointment. While this approach was consistent with previously defined roles, it proved not to be particularly efficient for the staff, and complicated the process for families. Thus, a countermeasure to address this problem

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involved redistributing work between the intake staff and the scheduler. The intake coordinators scheduled appointments upon completion of the intake interview, while the scheduler took on some of the non-clinical tasks previously completed by the intake staff.

Another important countermeasure involved the review of patient charts one week prior to initial visits of those patients scheduled at the time of intake to determine if parent and/or teacher questionnaires had been received. For those patients whose questionnaires were not yet received, the team leader placed follow-up phone calls to the parents to reiterate the importance of the questionnaires to ensure an efficient and accurate evaluation. Furthermore, the verbal and written information provided to families upon scheduling was revised to more clearly emphasize the importance of completing and returning parent and teacher questionnaires to allow for the most comprehensive and efficient visit.

Once the success of scheduling 2-year-olds was realized the process was then extended to all preschool-aged children within six months. Four months later, in January 2006, the process was expanded to children in kindergarten. By May 2006 it is expected that the improved intake and scheduling system will be applied, incrementally, to the entire CDU patient population.

Results Telephone calls answered by intake staff rather than the voice mail system increased from 0% to 75%. Telephone calls unable to be answered by the intake staff or received after hours were returned within 24 hours.

By simplifying the intake and scheduling system and removing wasteful work from the processes, wait time from the initial call to the date of the initial appointment declined by an average of a 53%. The time involved for intake and the family to connect via telephone was reduced from 1.83 days to less than one day. When the project started, the time between the intake interview completion and return of questionnaires to the CDU averaged 26 days; from the time the scheduling letter was sent to the family to the date the appointment was scheduled averaged 11 days. Both of these steps were eliminated entirely. The time between the date the appointment was scheduled to the date the patient was seen was reduced from 69 days to 52 days. Overall, wait time was reduced from an average of 110 days to 52 days.

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The following chart compares cycle times prior to and after implementation:

ACTIVITY

CYCLE TIME PRIOR TO FEB. '05 (number of

days)

CYCLE TIME AS OF OCTOBER '05 (Number of

days) Days for Intake and Family to

connect via phone 1.83 <1 Date of intake to date forms

are received back from family 26 0 Date parent forms received to

date scheduling letter sent 2 0 Date scheduling letter sent to date appointment is scheduled 11 0 Date appointment is scheduled

to date child is seen for evaluation 69 52

TOTAL 110 52

(Italicized font indicates steps that were eliminated from the intake/scheduling processes)

In addition to results realized in reducing wait time until appointment, intake staff reported qualitative improvements to their work flow. For example, while answering telephone calls in real time increased the pace of their work, it reduced the stress of continuously being behind in returning calls. Now, rather than starting the day with a back log of upwards of 60 telephone calls to return, only the calls received after hours or while both intake coordinators were serving other callers needed to be returned. The staff report being relieved by beginning each day with a virtually “clean slate.”

Discussion The Perfecting Patient Care System™ has demonstrated that principles designed for

the manufacturing industry can be applied in the health care setting. Applying the principles of PPC in a clinical workplace is difficult work, and not every experiment is successful. But with every encounter, participants learn more and apply what they learn.

The CDU project, as elsewhere, has demonstrated that it takes much more than the good will of the frontline workers to achieve breakthroughs. It takes an entire organization aligned around the idea of improvement and committed to its success. When work seems to be imposed by an outside entity, it rarely takes hold. But when championed by those inside the organization who are passionate about transformation, and supported by frontline workers who are passionate about improving the quality of the care they provide, organizational alignment and genuine change can occur.

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The fundamental principles of real-time problem solving, valuing the expertise of the people doing work to redesign it, and continuously striving toward the ideal have demonstrated promising results in the CDU. The successes obtained in improving the timeliness of service provision have been achieved by removing wasteful work from complicated systems.

Improving appointment timeliness by removing wasteful work provides incentive for the team to continue the PPC approach to find more improvements. The team continues to strive toward the ideal of providing initial appointments to patients within 10 days of the request. The content of patient assessments will be assessed to determine whether care delivery can be further standardized. Efforts are currently under way to increase clinical staffing since the initial work assessment revealed that demand consistently exceeds capacity. Innovative care models are also being explored to determine if and how care may be delivered in non-traditional ways without compromising quality.

PPC is rooted in Toyota’s 50 years of experience in creating a culture where continuous improvement is ingrained in daily work. The challenge posed to health care and other industries that attempt to adopt PPC is to incorporate the model into the culture and daily activities of workers throughout the organization. Implementation of the model presents challenges, for it requires readiness for change on the part of workers at all levels of the organization, as well as a significant shift in thinking from traditional systems of process improvement. Once implementation is accomplished the challenge continues, for sustaining the philosophical tenets and ingraining them into the culture and daily work can be an uphill battle. The successful implementation and sustainability of PPC requires not only employing the “tools,” but the fundamental philosophies of valuing customers and employees and creating an environment in which the full potential of employees may be realized. The success achieved thus far with implementation of PPC in the CDU to improve access to diagnostic services suggests that improvement methods adapted from industry have promise for improving outcomes for health care workers and consumers in today’s challenging health care market.

Table 1 Rules In Use

Activities. Work must be highly specified as to content , sequence, timing, location and expected outcome Connections between customers and suppliers must be highly specified , direct with a clear yes-or-no way to send requests and receive responses The pathway for every product and service must be predefined and highly specified , simple and direct – no loops or forks Improvements are made using the scientific method with guidance from a teacher, as close as possible to the front line aiming for the ideal.

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i Kohn, Linda T., Corrigan, Janet M., and Donaldson, Molla S., Editors. To Err is Human: Building a Safer Health System, Committee on Quality of Health Care in America Institute of Medicine, National Academy Press, Washington, D.C., 1999. ii Compton, W.D. and Grossman, J.H. Building a Better Delivery System: A New Engineering/Health Care Partnership, Washington D.C. National Academy Press, 2005. iii Ibid. ivCharman,T. & Baird, G. (2002). Practitioner Review: Diagnosis of autism spectrum disorder in 2- and 3-year-old children. Journal of Child Psychology & Psychiatry, 43(3), 289-305. v Kabot, S.Masi, W. & Segal, M. (2003). Advances in the diagnosis and treatment of autistic spectrum disorders. Professional Psychology: Research & Practice, 34(1), 26-33. vi Spear, Steven. Teaching Note Deaconess Glover Hospital (A), (B),(C),(D),( E) and(F) Harvard Business School N5-602-075. 2001. vii http://www.jdpower.com/news/releases/pressrelease.asp?ID=2005069 accessed 2/21/06 viii Toyota Manufacturing Company Annual 2005, http://www.toyota.co.jp/en/ir/library/annual/2005/president/index.html accessed february 26, 2006 ix http://www.cbsnews.com/stories/2005/12/20/business/main1141233.shtml accessed february 26, 2006 x Notes from TSSC Kaizen Leader TPS Workshop December 19-19,2001 Hebron, Kentucky xi Ibid. xii Ohno, T. Toyota Production System Beyond Large Scale Production. Portland Oregon: Productivity Press. 1988; xiii Liker, J., The Toyota Way: 14 Management Principles from the World’s Greatest Manufacturer. New York: McGraw Hill. 2004 :13 xiv Ibid. xv Spear, S. and Bowen, H.K. “Decoding the DNA of the Toyota Production System. Harvard Business Review. 1999;77(5):96-106 xvi Committee of Quality of Health Care in America. Crossing the Quality Chasm A New Health System for the 21st Century. Washington, D.C. The National Academies Press 2001. :309-317 xvii Ibid: 314.

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http://www.jdpower.com/news/releases/pressrelease.asp?ID=2005069

http://www.toyota.co.jp/en/ir/library/annual/2005/president/index.html%20accessed%20february%2026

http://www.cbsnews.com/stories/2005/12/20/business/main1141233.shtml%20accessed%20february%2026

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Perfecting Patient Care: Applying the Industrial Model in … · 2008-12-23 · Perfecting Patient Care: Applying the Industrial Model in Healthcare (004-0074 ) Debra Thompson, Pittsburgh