Voice of the Customer Voice of the Customer

to Identify Process to Identify Process

Improvement ProjectsImprovement Projects

Darcy PrejeantDarcy Prejeant

May 12, 2010May 12, 2010

Thibodaux

Community HospitalCommunity Hospital

185 Beds185 Beds

950 Team Members950 Team Members

ER VisitsER Visits -- 32K32K

ER Beds ER Beds –– 12 & 2 12 & 2 Fast TrackFast Track

Going to 26 bedsGoing to 26 beds

Topics of DiscussionTopics of Discussion

•• Press Press GaneyGaney Patient SatisfactionPatient Satisfaction

•• Voice of the Customer (VOC)Voice of the Customer (VOC)

•• Projects to Achieve AccomplishmentsProjects to Achieve Accomplishments

Patient Satisfaction ResultsSeptember 06 – November 07Patient Satisfaction ResultsPatient Satisfaction Results

September 06 September 06 –– November 07November 07

9797

9797

9797

9898

9999

OUTPTOUTPT

9898939343432626thth QuarterQuarter

9999959563632727thth QuarterQuarter

9999919176762828thth QuarterQuarter

9999909054542929thth QuarterQuarter

9999979737373030thth QuarterQuarter

INPTINPTACUACUEDED

Measure

What do we want to know? What are we measuring?

• Y: Each individual patient’s satisfaction with the ED• Defect: Any score on Press Ganey less than 5• Baseline: 3/1/2001-5/31/2001

Impact on Business: Increased growth and revenue; approximately 45% of admits originate in ED

Questions D U Z.B Prob of DefectLikelihood to Recommend 69 156 1.64 44%Nurses informative re treatments 80 160 0.00 50%Staff Cared About You as a Person 75 159 1.57 47%Kept Informed About Delays 89 146 0.00 61%Care Worth $ Charged 83 142 0.00 58%

ED Patient Satisfaction

AttitudeAttitude -- Our patients are our top priority. We are committed to providiOur patients are our top priority. We are committed to providing the ng the highest quality of service & meeting our customershighest quality of service & meeting our customers’’ needs with needs with care & courtesycare & courtesy..

Customer WaitingCustomer Waiting -- We realize that our customerWe realize that our customer’’ s time is very valuable. We s time is very valuable. We strive to provide our customers with prompt service, strive to provide our customers with prompt service, keeping them informed of keeping them informed of delaysdelays and making them and making them comfortable while they waitcomfortable while they wait. .

Standard Six Sigma Solutions Treat everyone as if he or she is the most important person in the facility.

Staff will make face-to-face contact every 30 minutes (at a minimum).

Body language, tone and demeanor should also reflect a positive attitude.

UCs are committed to improving patient satisfaction. Each staff member set personal goals to improve patient satisfaction.

Educate families on process. Family members need to know that procedures generally do not begin as soon as the customers enter the area.

A brochure is in development which will explain the ED process to customers.

Direct patients/families to designated areas for refreshments and provide reading materials to waiting families.

Vending machines will be put into Waiting Room. Magazine, puzzle pages and color pages available.

TRMC Standards of PerformanceImprove

Voice of CustomersVoice of Customers

•• Doctors Doctors -- Too slowToo slow to get labsto get labs

•• Patient Patient -- WaitWait too long to see doctortoo long to see doctor

•• Staff Staff –– No consistencyNo consistency in processesin processes

•• Son of patient Son of patient –– ““Staff arenStaff aren’’t personablet personable””

Many Tools Many Tools ……

One ToolboxOne Toolbox•• Six SigmaSix Sigma

•• LAB Turn Around TimesLAB Turn Around Times

•• STEMI ProjectSTEMI Project

•• LeanLean•• ED Workflow Team ED Workflow Team

•• ED Low Acuity Management Team ED Low Acuity Management Team

•• ED IP Bed Request to Depart TeamED IP Bed Request to Depart Team

•• 5S5S•• DoctorDoctor’’s dictation rooms dictation room

•• Work outWork out•• Transport to & from RADTransport to & from RAD

•• CAPCAP•• Help staff to understand why changes are neededHelp staff to understand why changes are needed

Develop Team Charter

Problem Statement: From March 2007 through May 2007, the turn-around time from the time the physician’s order for lab tests is entered into Meditech to availability of the results in the ED exceeds acceptable performance limits for delivering timely patient care in the ED.

Problem Statement: Problem Statement: From March 2007 through May 2007, the From March 2007 through May 2007, the turnturn--around time from the time the around time from the time the physicianphysician’’s order for lab tests is entered s order for lab tests is entered into into MeditechMeditech to availability of the to availability of the results in the ED exceeds acceptable results in the ED exceeds acceptable performance limits for delivering timely performance limits for delivering timely patient care in the ED. patient care in the ED.

Business Case: The project will focus on improving efficiency in turn-around time between the ED and Lab. This will positively impact patient, physician, and employee satisfaction. Financial benefits will be realized with an increase in patient satisfaction & fewer patients leaving without being seen. It is important to do it now because of increased competition in our service area & to align with the ED initiative for quality improvements before new construction begins.

Business CaseBusiness Case: :

The project will focus on improving The project will focus on improving efficiency in turnefficiency in turn--around time between around time between the ED and Lab. This will positively the ED and Lab. This will positively impact patient, physician, and employee impact patient, physician, and employee satisfaction. Financial benefits will be satisfaction. Financial benefits will be realized with an increase in patient realized with an increase in patient satisfaction & fewer patients leaving satisfaction & fewer patients leaving without being seen. It is important to do without being seen. It is important to do it now because of increased competition it now because of increased competition in our service area & to align with the ED in our service area & to align with the ED initiative for quality improvements initiative for quality improvements before new construction begins. before new construction begins.

Goal Statement:

To reduce the overall turn-around time for ED/Lab testing for blood specimens from 47 min to less than 45 min & to reduce the standard deviation from 25 min to less than 15 min by January 2008.

To maintain the overall turn-around time for ED/Lab testing for urine specimens to be less than 30 min (currently 28 min) & to reduce standard deviation from 18 min to less than 15 min by January 2008.

Goal Statement:Goal Statement:

To reduce the overall turnTo reduce the overall turn--around time for around time for ED/Lab testing for blood specimens from ED/Lab testing for blood specimens from 47 min to less than 45 min & to reduce the 47 min to less than 45 min & to reduce the standard deviation from 25 min to less than standard deviation from 25 min to less than 15 min by January 2008. 15 min by January 2008.

To maintain the overall turnTo maintain the overall turn--around time around time for ED/Lab testing for urine specimens to for ED/Lab testing for urine specimens to be less than 30 min (currently 28 min) & to be less than 30 min (currently 28 min) & to reduce standard deviation from 18 min to reduce standard deviation from 18 min to less than 15 min by January 2008.less than 15 min by January 2008.

Scope:Start:MD’s order for lab test is entered into MeditechStop: Availability of results

Defect: Blood: TAT > 45 minutesUrine: TAT > 30 minutes

Scope:Scope:Start:Start:MDMD’’s order for lab test is entered into s order for lab test is entered into MeditechMeditechStop:Stop: Availability of results Availability of results

DefectDefect: : Blood: TAT > 45 minutesBlood: TAT > 45 minutesUrine: TAT > 30 minutesUrine: TAT > 30 minutes

ED Lab TATED Lab TAT

Critical Xs- Analytical Process (Lab)

Implemented Stat Lab

Implemented interface

Implemented phone system

Implemented new process

Action Plan

CompleteER specimens getting caught up in process

Lab specimen volume

CompleteDelays due to manual verification process

Verification of results

CompleteUnable to reach appropriate person for reporting

Reporting panic results

CompleteNo SOP for central processing in Lab

Removing specimen from tube system

StatusRoot CausesCritical Xs

STAT Lab

• Prioritized ED Lab Specimens

• Dedicated Med Tech owns ED analysis

• Installed new lab equipment to facilitate ED specimen flow

• Eliminated need for Point of Care testing

STAT Lab Data

ED Collection Lab TestingEntered Receive Result

Enter to Result

Pre-Analytical Analytical

102181478Jan-08Test

182513191510Aug-07Urine

Std DevMeanStd DevMeanStd DevMean

TotalAnalyticalPre-analytical

194514231422Jan-08Test

254715231825Aug-07Blood

Std DevMeanStd DevMeanStd DevMean

TotalAnalyticalPre-analytical

Data Analysis

Is the reduction in means & variance significant?

Two-Sample T-Test and CI Sample N Mean StDev SE Mean1 1792 28.0 18.0 0.432 556 22.0 10.0 0.4295% lower bound for difference: 5.01165P-Value = 0.000

Test for Equal Variances - Blood95% Bonferroni confidence intervals for SDSample N Lower StDev Upper

1 8292 4.91441 5.00000 5.088522 2283 4.21878 4.35890 4.50829

F-Test (normal distribution) Test statistic = 1.32P-value = 0.000

Two-Sample T-Test and CI Blood Sample N Mean StDev SE Mean1 8292 47.0 25.0 0.272 2283 45.0 19.0 0.4095% lower bound for difference: 1.20502P-Value = 0.000

Test for Equal Variances 95% Bonferroni confidence intervals for SDSample N Lower StDev Upper

1 1792 3.73302 3.87298 4.023462 556 2.96258 3.16228 3.38972

F-Test (normal distribution) Test statistic = 1.50P-value = 0.000

ED Workflow TeamED Workflow Team

Goal: Improve ED Workflow processes to facilitate patient care and improve satisfaction.

Includes: Communication, Chart Flow, Standard Work, Ancillary Services, etc)

Improvements:

• Revamp White Board – Visualize flow and communication tool

• UC, Tech, Unit Secretary, RN, Radiology, CP – all have role in updating board

• Task Binder - Daily/weekly compliance tasks…to drive accountability

• Ancillary Services - Radiology Transport Work Out

• Identified Detailed Roles & Responsibilities

• Outlined Unit Coordinator role focus on directing patient flow

New ED Whiteboard – visual communication of flow

Bed # Patient Name RNTime of Arrival

MD Tech Vitals RAD CARD RESPConsult

MDDispo

Blood Urine

Trauma 1 Smith Renee 15:20 O Diana 16:02 Patel Adm 260

Trauma 2 Renee Diana

Trauma 3 Jones Renee 13:12 O Diana 15:40 Disch

Medical Renee Diana

Major Trauma 1 Leslie Diana

Major Trauma 2 Leslie Diana

Cast Leslie Diana

Exam 1 Cindy Shane

Exam 2 Cindy Shane

Exam 3 Cindy Shane

Exam 4 Cindy Shane

Desk 1 Shane

Desk 2 Shane

Desk 3 Shane

RA 1

RA 2

LAB

Person whom places patient in ED Room –RN, UC, Tech, Triage RN

UCUCUCUC

Tech updates vital timestamp, places checkmark when done with Lab draws, EKG, Radiology. Places/Removes magnet when taking patient to/from Radiology.

RNRNRNRN RNRNRNRN RNRNRNRN

Unit Secretary adds checkmarks when item is ordered/resulted. Adds a green magnet next to Radiology when Radiology is ready.

RN RN RN RN –––– may update labsmay update labsmay update labsmay update labs…………

CPCPCPCPRADRADRADRAD

ED Low Acuity ED Low Acuity

Management TeamManagement Team

Goal: Improve management of low acuity patients to facilitate patient care and improve satisfaction (i.e. protocols, triage, fast track, rapid assessment, customer service)

Improvements:

• Implement 5-Level Triage Acuity Level Scale

• Create process to implement Rapid Assessment of Low Acuity Patients

• Utilize 2 rooms to see acuity Level 4’s & 5’s patients

• Relocate ED Director’s office and staff lounge

• Review ED Nurse Protocols for Triage & Treatment

• Concept of Stat Lab for ED located in the Lab

• POE Collection process in the ED

ED IP Bed Request to ED IP Bed Request to

Depart TeamDepart Team

Goal:Goal: Improve the inImprove the in--patient bed request process to facilitate patient bed request process to facilitate

patient care, improve satisfaction and reduce ED length of stay.patient care, improve satisfaction and reduce ED length of stay.

Improvements:Improvements:•• ED Nurse ReportED Nurse Report

••Implemented 20 minute fax rule if report not takenImplemented 20 minute fax rule if report not taken

••SURGE Plan SURGE Plan

•• Began as ED Plan & turned into hospital wideBegan as ED Plan & turned into hospital wide

•• Utilize a point system to categorize into a color Utilize a point system to categorize into a color Red / Yellow / GreenRed / Yellow / Green

•• Identified definitions for reaching the colorsIdentified definitions for reaching the colors

ED Surge Plan

• Standardized & coordinated actions to improve patient flow

• Detailed actions defined by role that need to be done to maintain or return ED to normal status (Green)

• Utilized a quantitative point system to determine ED status (Red, Yellow, Green)

Progress Continues Progress Continues

Through CAPThrough CAP

•• Regular Staff meetings to explain the importance of changeRegular Staff meetings to explain the importance of change

•• Back to the basics with staff becauseBack to the basics with staff because

•• ““You get what you tolerateYou get what you tolerate””

•• Terminated staff who did not fit into our cultureTerminated staff who did not fit into our culture

•• Ground Rules Ground Rules –– ““Standards of PerformanceStandards of Performance””

•• Weekly meetings w/ Weekly meetings w/ UCsUCs, ET Sponsor, IP Director & ED , ET Sponsor, IP Director & ED

EducatorEducator

•• Daily Team HuddlesDaily Team Huddles

A Plan to Make a A Plan to Make a

DifferenceDifference

•• Implemented Implemented AIDETAIDET

•• Acknowledge, Introduce, Duration, Explain, ThankAcknowledge, Introduce, Duration, Explain, Thank

•• Focused on TATFocused on TAT

•• Pull Pull tiltil fullfull

•• Daily Midlevel Daily Midlevel

•• Load TREAT rooms earlyLoad TREAT rooms early

•• Hospital wide surge planHospital wide surge plan-- bed huddlesbed huddles

•• Post metrics dailyPost metrics daily

•• Discharge Phone CallsDischarge Phone Calls

•• Leader Rounding Leader Rounding

•• Bedside RegistrationBedside Registration

Results Sustained

ER Metric Type GoalJan - Sept

2008Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 FY09

ER Patient Census Count - 23577 2545 2719 2538 2723 2988 3134 16647median minutes 168 118 141 130 137 136 136 140

Std Dev 131 112 119 111 117 115 98 121% met goal 38% 58% 49% 54% 51% 51% 51% 50%

median minutes 248 227 234 214 231 242 232 237

% met goal 25% 32% 26% 36% 28% 25% 28% 27%

median minutes 156 101 123 117 122 121 123 125% met goal 34% 59% 48% 51% 48% 49% 48% 47%

ER Patient Census - TREAT Count - 2771 315 362 356 453 641 736 2863

median minutes 119 68 65 67 70 77 84 81Std Dev 83 53 40 60 54 52 49 59

% met goal 14% 39% 43% 42% 39% 35% 29% 30%

Door to Doctor - TREAT mean minutes - 85 39 38 47 44 49 60 51

Left without being seen Percentage <2% 6.4% 1.3% 2.5% 2.2% 1.8% 2.9% 2.5% 2.6%

LAMA Percentage <1% 0.6% 0.4% 0.5% 0.4% 0.2% 0.4% 0.6% 0.4%

45 44 45 45 44 48 44 44 4515 19 22 22 22 23 23 21 2230 22 24 22 22 22 23 24 2415 13 14 14 12 13 15 15 14

Left Without Being Seen

Length of Stay - TREAT 60

TREAT - Thibodaux Regional Emergency Acuity Treatme nt

Length of Stay - Discharge Home

120

Length of Stay - Admitted 180

Emergency Department Operational Dashboard

ER Cycle Time

Length of Stay - ALL Patients 140

Lab TAT

Lab TAT - Blood Time

Lab TAT - Urine Time

LOS Improvements LOS Improvements

168156

119

140125

81

126

109

70

0

20

40

60

80

100

120

140

160

180

Overall LOS Discharged Home LOS TREAT LOS

Jan 2008 - Sept 2008

Oct- 2008 -Sept 2009

Oct 2009 - Feb 2010

25%25%

30%30%

41%41%

Left Without Being SeenLeft Without Being Seen

LWBS

6.4%

2.6% 2.3%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

Jan 2008 - Sept 2008 Oct- 2008 -Sept 2009 Oct 2009 - Feb 21010

64%64%

Progress in Progress in

Press Press GaneyGaney Scores Scores

Press Ganey Scores from Sept 2007 to Date

37%45%

31%

51%

35%

50%

89%79% 81% 81%

0%10%20%30%40%50%60%70%80%90%

100%

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Solutions

ProjectChange

Leadership

Vision to RealityVision to Reality