Applying Lean Principles to a Continuing Care Patient Discharge … · learned in class to a field...

Applying Lean Principles Applying Lean Principles to a Continuing Careto a Continuing CarePatient Discharge ProcessPatient Discharge Process

Graduate Students:Graduate Students:Amy ThompsonAmy Thompson

Paul Paul HossfieldHossfieldStephen AbbyStephen Abby

Presenter:Presenter:Valerie MaierValerie Maier--SperedelozziSperedelozziAssistant Professor, IndustrialAssistant Professor, Industrialand Manufacturing Engineeringand Manufacturing Engineering

TopicsTopics

Literature Review and Issues in Lean HealthcareLiterature Review and Issues in Lean HealthcareHospital Level Value StreamHospital Level Value StreamContinuing CareContinuing Care

Current and Future Value Stream MapCurrent and Future Value Stream MapPostPost--Discharge OrderDischarge Order

Current and Future Value Stream MapCurrent and Future Value Stream MapApplied Lean TechniquesApplied Lean Techniques

Standardized WorkStandardized WorkVisual Display and ControlsVisual Display and Controls

SummarySummary

ErrorError--ProofingProofing5S5S

Project ScopeProject Scope

New Graduate Level Course in Lean New Graduate Level Course in Lean Manufacturing SystemsManufacturing SystemsTeam Project Team Project –– Apply lean principles Apply lean principles learned in class to a field other than learned in class to a field other than manufacturingmanufacturing

HealthcareHealthcareRestaurantRestaurant

Create current and future state mapsCreate current and future state mapsSelect at least 2 other lean techniquesSelect at least 2 other lean techniques

Retail DistributionRetail DistributionSmall BusinessSmall Business

Literature ReviewLiterature Review

Womack and Jones, Womack and Jones, Lean ThinkingLean Thinking, 1996, 1996Proposed how lean techniques could be Proposed how lean techniques could be applied to servicesapplied to servicesHospital should focus on effectiveness, rather Hospital should focus on effectiveness, rather than efficiency and utilization of resources than efficiency and utilization of resources [4][4]

Hospital Board members with experience Hospital Board members with experience in manufacturing emphasize lean in manufacturing emphasize lean implementation implementation [6][6]


Lean can be applied toLean can be applied toOrdering systemsOrdering systemsLead time and throughputLead time and throughputAdmissions and DischargeAdmissions and Discharge

Metrics for hospital performanceMetrics for hospital performance# infections per 1000 patients# infections per 1000 patientsDirect care % by caregiversDirect care % by caregiversOverpayment by insurersOverpayment by insurers# of complications# of complications

Bed AvailabilityBed AvailabilityWaiting roomsWaiting roomsLinen distributionLinen distribution

# of forms# of formsLength of stayLength of stayValue added timeValue added timeThroughput timeThroughput time

[2, 3, 5, 6, 7][2, 3, 5, 6, 7]


Lean apprehension Lean apprehension [1] [5][1] [5]

Some healthcare practitioners associate “lean” Some healthcare practitioners associate “lean” with lean staffingwith lean staffingEmployees fear job cuts, layoffs, staff Employees fear job cuts, layoffs, staff reductionreductionAs in manufacturing, a major goal of lean As in manufacturing, a major goal of lean implementation is actually job securityimplementation is actually job securityTouring lean manufacturing facilities can helpTouring lean manufacturing facilities can help

Int’l. J. of Prod. Economics Article Int’l. J. of Prod. Economics Article by by LluisLluis ArbosArbos, 2002, 2002

Differential Characteristics of Products and ServicesDifferential Characteristics of Products and ServicesTransfer of ownershipTransfer of ownershipTangible vs. intangible nature of satisfactionTangible vs. intangible nature of satisfactionProduct can be stored, services generally can notProduct can be stored, services generally can notHigh variability in service tasks, methods, lengthHigh variability in service tasks, methods, lengthProductive process can coincide with enjoymentProductive process can coincide with enjoymentCustomer can take part in delivery (selfCustomer can take part in delivery (self--service)service)“In“In--situ” services performed where client is locatedsitu” services performed where client is locatedDegree of contact with customerDegree of contact with customerVery low flexibility due to highly specialized Very low flexibility due to highly specialized employeesemployees

HospitalHospital--Level Value Stream MapLevel Value Stream Map

FlowFlowGroupings and Layout by ProcessGroupings and Layout by ProcessUnique patient treatments grouped by Unique patient treatments grouped by similaritiessimilaritiesMostly OneMostly One--Piece, Unbalanced FlowPiece, Unbalanced FlowNonNon--Pull, NonPull, Non--JIT, No FIFOJIT, No FIFO

Patient does not determine flowPatient does not determine flowCan not pull from end of value streamCan not pull from end of value streamCan not inventory wellnessCan not inventory wellness


Quality FeedbackQuality FeedbackBuiltBuilt--In Quality (In Quality (JidokaJidoka) in most individual ) in most individual pieces of healthcare equipment, instruments pieces of healthcare equipment, instruments and toolsand toolsRecursive Customer InterviewsRecursive Customer InterviewsRecursive Physical Condition ChecksRecursive Physical Condition ChecksRecursive Checks of Medical RecordsRecursive Checks of Medical RecordsCustomer Satisfaction SurveyCustomer Satisfaction SurveyNational Quality Auditing Agencies & National Quality Auditing Agencies & RegulatorsRegulators


MeasurementsMeasurementsLength of Stay (LOS)Length of Stay (LOS)Customer SatisfactionCustomer Satisfaction

Issues in Hospital Value StreamIssues in Hospital Value StreamNonNon--Deterministic Arrivals, Processing Times, Deterministic Arrivals, Processing Times, and Outcomesand OutcomesRecursion and Parallelism on “Critical Path”Recursion and Parallelism on “Critical Path”Highly Specialized EmployeesHighly Specialized Employees

Waiting Area Estimated Capacity: 10 Estimated Average Wait: 30 minutes

Waiting Area Estimated Capacity: 10 Estimated Average Wait: 45 min.

Quality Management

Facilities & BMET Services

Elective Surgical Patient

Pre- Admission Testing

Same Day Admission

Holding Unit Operating Room

Recovery Room

Nursing Care Unit

Discharge: Case Management

Diagnostic Test & Services

Labs, EEG/EMG, Cardiac Testing, Radiology, PFT

Central Supply & Laundry Services

Information Services

Hospital Support Services

Case Management

Social Work

Nursing Support

Dietary

PT/OT

Respiratory Services

Hospital Support Services

Supplier: Public

Estimated Arrival Rate: 48 per day

I

Waiting Area Estimated Capacity: 15 Estimated Average Wait: 60 min.

Physicians

Estimated Capacity: 5 C/T: 75 min. Uptime:81.25%



Nursing

I I




House Keeping Services


5 2 4 2 2 2 5

Treated Patient

Customer: Public

Supplier = Customer

60 min. 45 min. 30 min.

75 min. 105 min. 1620 min.

Total Throughput Time: 1935 minutes = 32.25 hours Value Added Time: 1800 minutes = 30 hours Non-Value Added Time: 135 minutes = 2.25 hours Target Waiting Rooms and Find Non-Value Added Time Within PACU, NCU, and the Discharge Process

Shift = 8 hours Lunch = 1 hour (2) Breaks, 15 minutes each Uptime = 6.5/8.0=81.25%

Continuing CareContinuing Care

Arrange care for postArrange care for post--hospital recoveryhospital recoveryEducate family and patient on conditions, Educate family and patient on conditions, treatments, and care during and after treatments, and care during and after hospital stayhospital stayAssure patients are prepared to leave Assure patients are prepared to leave when dischargedwhen discharged

Average Wait:

12 hours

Average Wait: 20 hrs.

Average Wait: 24 hrs (x 2)

Average Wait: 1 min.



Average Wait:

4 hours

7 Patients

1Patients

1Patients

1Patients

7Patients

7Patients

7 Patients

Supplier = Customer Continuing Care (CC) Department Value Stream Map

Utilization Review

Supplies

Laboratory

Admitting

Administration

Health Information Services

MEDITECH

Risk Management Patient Financial Services

Performance Improvement

Communications

Medical Standards and Review

Dietary

Social Work

Rehabilitation

Physical, Occupational, and Speech Therapy

Cardio-Pulmonary Services

Physicians and Medical Staff

Nursing Staff

Capacity: 109 Ave. C/T: 25 min. Min: 5 min. Max: 4 hrs. Uptime: 27% PR: CC Staff PROCEDURE SECTION III Forms: Multi-Disciplinary Assessment, Mini-Mental

CC Assesses CC Patient

Status & Needs

Capacity: 109 Ave. C/T: 1 min. Batch Process occurs once per day, Ave. Batch Size = 13 Uptime: 3.1% PR: CC Staff PROCEDURE SECTION I and II Forms: Demographics/ Face Sheet, Start Checklist

Capacity: 109 Ave. C/T: 12 min. C/T: 5 min. Lev. of Care C/T: 5 min. ID Screen C/T: 3 hours for PASSR Uptime: 27 % PR: CC Staff PROCEDURE SECTION IV and UR POLICY SECTION I Forms: Level of Care Assessment, ID Screen and PASSR

Capacity: 109 Ave. C/T: 15 min. Uptime: 27 % PR: CC Staff PROCEDURE SECTION V Forms: Multi-Disciplinary Assessment

Create & Review CC Patient

Discharge Plan

Capacity: 109 Ave. C/T: 35 min. Uptime: 27 % PR: CC Staff PROCEDURE SECTION VI Forms: Multi-Disciplinary Assessment, Continuity of Care Referral, Nursing Facility Referral, Maternity Early Discharge Activities: Psychiatric Transfers, Abuse Services

Estimated Capacity: 109 Ave. C/T: 3 hours Value Added: 15 min. Non-Value Added: 165 min. Min: When Family Max: When Transfer Uptime: 27 % PR: CC Staff PROCEDURE SECTION X Forms: Complete CC Checklist, Complete all CC Documentation and Forms

Perform Discharge Once

Order Given

Estimated Capacity: 109 Ave. C/T: 15 min. Uptime: 27 % PR: CC Staff PROCEDURE SECTION VII Forms: Any Necessary

Reassess Discharge Plan

Periodically

3 3 3 3 3 3 3

Assign a Level of Care, ID Screen,

PASSR

Identify Patient for CC

Implement Discharge Plan

A Continuing Care (CC) Patient

AND MEDICAL CHART

Supplier: Local Community

Average Arrival Rate: 13 per day

InsuranceAgency

Family

Continuing Care Services(Nursing Homes, Skilled Home Care

Agencies, Community Resources)

HOSPITAL

AVERAGE LOS = 3.7 days Value Added Time: 133 minutes Non-Value Added Time: 165 minutes Wait Time = Rest/ Treatment Time =86.9 hrs.

Assume Time Occurring Between CC Steps is Value-Added to Patient as Rest and Required Testing and Procedures

Ave. Throughput Time = 3.71 days

Shift = 8 hours Lunch = 1 hour 2 Breaks, 15 minutes each Total Uptime on 24 hour Day = 27%

Treated Patient

Customer: Local Community

CC Non-Value Stream Activities (Support)

KEY SYMBOL PATIENT MEDICAL RECORD CC FILE COMMUNICATION (ALL COLORS) REPEAT STEP

1 minute 25 minutes 12 minutes 15 minutes (x 2)35 minutes 180 minutes15 minutes

EXTERNAL CUSTOMERS

24 Hour Mark

CARE UNIT DIVISION BY CCC WING A 18 EMERGENCY (ER) 15 HOLDING (AR) 4 NURSERY 16 PEDIATRICS 4 WING B (26) ICU 8 WING C (18) SAME DAY SURGERY (FLEX)

House Keeping / Infection Control

Continuing CareContinuing Care

Current Value Current Value Stream MapStream Map

Summary TableSummary Table

A* NVA VA

Wait # 1 720

Identify Patient for CC 1

Wait # 2 240

CC Assesses CC Patient Status & Needs 25

Wait # 3 1

Assign a Level of Care 12

Wait # 4 1

Create & Review Discharge Plan 15

Wait # 5 1

Implement Discharge Plan 35

Wait # 6 2880

Reassess Discharge Plan Periodically 30

Wait # 7 1200

Perform Discharge Once Order Given 165 15

Minutes 5043 165 133Minutes 1335208

CC Department Level Activities

*A is Treatment, Rest, and Wait Time** NVA is Categorized Non-Value Added Activity

***VA is Value Added

Continuing CareContinuing CareFuture Value Stream MapFuture Value Stream Map

Reduce time from when the discharge Reduce time from when the discharge order is given by the physician to when order is given by the physician to when the patient is actually dischargedthe patient is actually discharged

FreeFree--up bed soonerup bed soonerLess work for CC Coordinators to do the day Less work for CC Coordinators to do the day of dischargeof dischargeImprove service quality and discharge speed Improve service quality and discharge speed to improve customer satisfactionto improve customer satisfaction

Customer Satisfaction Survey:Customer Satisfaction Survey:Discharge ProcessDischarge Process

Extent to which you felt ready to be Extent to which you felt ready to be discharged.discharged.Speed of discharge process after you were Speed of discharge process after you were told you could go home.told you could go home.Instructions given about how to care for Instructions given about how to care for yourself at home.yourself at home.Help with arranging home care services if Help with arranging home care services if needed.needed.

FLAG THE PATIENT FILE IF THE PATIENT IS A CC PATIENT (COLORED FLAG)

ALERT PATIENT OF DISCHARGE

IS PATIENT A CONTINUING

CARE PATIENT?

COORDINATE TRANSPORTATION

PULL CCPATIENT DOCUMENTS

PERFORM CHECKS:SERVICESDOCUMENTSINSURANCE

PHYSICIAN GIVES DISCHARGE ORDER

(IN MEDICAL RECORD)

YESNOPHYSICIAN

DISCHARGES PATIENTFORM 851

1 CC PATIENT FILEON EACH FLOOR

MEDICAL RECORD(using Yellow Mark for Visual Methods)

FORM 851NON-CC PATIENTDISCHARGE FORM

CREATE A DISCHARGE CHECKSHEET FOR SERVICES DOCUMENTS AND

COMPLETE ANY REMAINING EXTERNAL SERVICE ARRANGEMENTS, DOCUMENTS OR INSURANCE CHECKS

EVERYTHINGCOMPLETE?

NO

YES

CC PATIENT FILE

CC PATIENT FILE

Current PostCurrent Post--Discharge Discharge Order ProcessOrder Process

Current PostCurrent Post--Discharge Discharge Order Process Order Process (cont.)(cont.)

ALERT FAMILY

NOTIFY NURSING TO COMPLETE

PAPERWORK

COPY RECORDS NEEDED FOR

TRANSMISSION & PLACE IN ENVELOPE IN

MEDICAL RECORD

NURSE FAXESCOPY OF DOCUMENTS

TO AGENCY

ARRANGE SUPPLIES TO BE SENT WITH PATIENT

NURSING HOME OR HOME CARE?

NURSING HOME HOME CARE

DELIVER ENVELOPE WITH RECORDS TO

AMBULANCE DRIVER

CC PATIENT FILEMEDICAL RECORD

MEDICAL RECORD

CC PATIENT FILE

CC PATIENT FILE

COPY OF RECORDSFROM CC PATIENTFILE

DOES A FORM OR MATERIAL REQ NEED TO BE FILLED OUT? NO

NURSE COMPLETES PAPERWORK ANDCOPIES RECORDS

NEEDED FOR TRANSMISSION

WHAT HAPPENS TO CC PATIENT FILE? HOW IS IT RETURNED FROM NURSE?

Current PostCurrent Post--Discharge Discharge Order Process Order Process (cont.)(cont.)

End

DOES A COPY OF DOCUMENTS GO TO

MEDICAL STANDARDS AND REVIEW?

YES

CC PATIENT DOCUMENTS FILED IN CC DEPARTMENT IN HOME CARE FILE OR NURSING HOME FILE

ALPHABETICALLY

SEND COPY OF DOCUMENTS TO REVIEW BOARD

NO

COPY OF RECORDSFROM CC PATIENTFILE

CC PATIENT FILE

ADMINISTRATOR INPUTS PATIENT INFO INTO CC DATABASE

CC PATIENT FILE

Improvements toImprovements toPostPost--Discharge Order ProcessDischarge Order Process

Transportation & CommunicationTransportation & CommunicationMaterialsMaterialsQuality Assurance: Services & EquipmentQuality Assurance: Services & EquipmentFinal Documentation ProcessingFinal Documentation Processing

Agreements with Transportation SuppliersAgreements with Transportation SuppliersCurrently must wait until discharge order is given to Currently must wait until discharge order is given to schedule/arrange for patient transportationschedule/arrange for patient transportationCurrently a delayed response for pickupCurrently a delayed response for pickup

Negotiate quicker response to request for transportNegotiate quicker response to request for transport“Intent to Discharge” notice the day before“Intent to Discharge” notice the day beforePush lean/JIT concepts back to transportation suppliersPush lean/JIT concepts back to transportation suppliers

Family Transport: Incorporate Beeper ServiceFamily Transport: Incorporate Beeper Service

Transportation & CommunicationTransportation & Communication

MaterialsMaterialsMove onMove on--line activities to offline activities to off--line: line: stage materials to be sent home with a patient stage materials to be sent home with a patient the day before expected dischargethe day before expected discharge

5S supply closets on each unit5S supply closets on each unitRemove unneeded/outdated materialsRemove unneeded/outdated materialsOrganize and SustainOrganize and SustainMake space for staging soonMake space for staging soon--toto--bebe--discharged discharged patient’s discharge materialspatient’s discharge materialsUse Visual Displays and ControlsUse Visual Displays and ControlsQuality feedback: Check items pulled for patient Quality feedback: Check items pulled for patient against Multiagainst Multi--Disciplinary Assessment FormDisciplinary Assessment Form

Quality AssuranceQuality Assurance

Currently No Assurance Methods to verifyCurrently No Assurance Methods to verifyAll services are arrangedAll services are arrangedAll equipment and materials are arrangedAll equipment and materials are arrangedTransportation is arrangedTransportation is arrangedPatient has received necessary information for Patient has received necessary information for continuing carecontinuing care

Quality Assurance would reduce delays, Quality Assurance would reduce delays, improve customer satisfaction and careimprove customer satisfaction and care

DocumentationDocumentation

Eliminate WasteEliminate WasteStandardized WorkStandardized WorkErrorError--ProofingProofing5S5SVisual Displays and ControlsVisual Displays and ControlsStreamlined a Data Entry ProcessStreamlined a Data Entry Process

Remove NonRemove Non--Value Added ActivitiesValue Added ActivitiesA* NVA VA NVA VA Curent

Total Removed On-Line

Off-Line

Wait # 1 720 Pull CC Patient File and Perform Checks 9 1 10 9 1 -

Identify Patient for CC 1 Complete Remaining Tasks 15 0 15 15 0 -

Wait # 2 240 Alert Patient 3 2 5 3 2 -CC Assesses CC Patient Status

& Needs 25 Alert Transportation 11 1 12 11 1 -

Wait # 3 1 Wait for Transport 90 0 90 85 5 -

Assign a Level of Care 12 Alert Family 0 1 1 0 1 -

Wait # 4 1 Arrange Supplies 0 10 10 10 0 10

Create & Review Discharge Plan 15 Process Documentation 0 20 20 20 0 20

Wait # 5 1 Patient Leaves with Docs 0 5 5 0 5 -

Implement Discharge Plan 35 AA Records Stats and Files 10 2 12 10 0 2

Wait # 6 2880 Minutes 138 42 180 15 32

Reassess Discharge Plan Periodically 30 Hours 2.30 0.70 3.00 0.25 0.53

Wait # 7 1200 Days 0.10 0.03 0.13 0.01 0.02

Perform Discharge Once Order Given 165 15

*A is Treatment, Rest, and Wait TimeMinutes 5043 165 133 ** NVA is Categorized Non-Value Added ActivityMinutes 133 ***VA is Value Added

New

5208

CC Department Level Activities Post Discharge Order Activities

Current

Future Value Stream MapFuture Value Stream Map

T o ta l : 1 5 m in . W a i t T im e : 5 m in (T a r g e t to r e d u c e w a i t t o 0 in fu tu r e )

(4 ) A v e r a g e W a i t f o r

T r a n sp o r t 5 m in .

7 P a t ie n t s

S u p p l i e r = C u s t o m e r P o s t - D is c h a r g e O r d e r F u t u r e V a lu e S t r e a m M a p

P h ys ic ia n s a n d M e d ic a l S ta f f

C a p a c i t y : 1 0 9 A v e . C /T : 2 m i n . V a lu e A d d e d : 2 m in . U p t i m e : 2 7 % P R : C C S t a f f P R O C E D U R E S E C T I O N X .b .i v . F o r m s :

( 2 ) A le r t P a t ie n t

C a p a c i t y : 1 0 9 A v e . C /T : 1 m i n . V a lu e A d d e d : 1 m in . U p t i m e : 2 7 % P R : C C S t a f f P R O C E D U R E S E C T I O N X .b .i .- i i . F o r m s :

C a p a c i t y : 1 0 9 A v e . C /T : 1 m i n . V a lu e A d d e d : 1 m in . U p t i m e : 2 7 % P R : C C S t a f f P R O C E D U R E S E C T I O N X .b .v . F o r m s :

C a p a c i t y : 1 0 9 A v e . C /T : 1 m i n . V a lu e A d d e d : 1 m in . U p t i m e : 2 7 % P R : C C S t a f f P R O C E D U R E S E C T I O N X .b .v i . F o r m s :

( 5 ) A le r t F a m i ly

E s t i m a t e d C a p a c i t y : 1 0 9 A v e . C /T : 5 m i n . V a lu e A d d e d : 5 m in . U p t i m e : 2 7 % P R : C C S t a f f P R O C E D U R E S E C T I O N X .b .v i i i .- x . F o r m s : A n y N e c e s s a r y

( 6 ) P a t ie n t L e a v e s w i th D o c u m e n ts

3 3 3 3 3

( 3 ) A le r t T r a n s p o r ta t io n

( 1 ) P u l l C C F i le a n d C h e c k f o r C o m p le t io n

A C o n t i n u i n g C a r e (C C ) D i s c h a rg e d P a t i en t

A N D M E D I C A L C H A R T W ith a D is c h a rg e O r d e r

S u p p li e r : L o c a l C o m m u n i t y

A v e r a g e A r r iv a l R a te : 1 3 p e r d a y

In s u ra n c e A g e n c y

F a m ily

C o n t in u in g C a re S e rv ic e s (N u rs in g H o m e s , S k i l le d H o m e C a re

A g e n c ie s , C o m m u n ity R e s o u rc e s )

H O S P I T A L

A v e . T h r o u g h p u t T im e = 1 5 m i n u t e s

S h if t = 8 h o u r s L u n c h = 3 0 m i n u t e s 1 B r e a k , 2 0 m i n u t e s T o t a l U p ti m e o n 2 4 h o u r D a y = 2 7 %

T r e a t e d P a t i en t

C u s to m e r : L o c a l C o m m u n i t y

K E Y S Y M B O L P A T I E N T M E D I C A L R E C O R D C C F I L E C O M M U N I C A T I O N ( A L L C O L O R S ) R E P E A T S T E P P H Y S I C A L A C T I V I T Y ( A L L C O L O R S )

1 m in u t e 2 m in u t e s 1 m in u t e 5 m in u t e s 1 m in u t e

E X T E R N A L C U S T O M E R S

C A R E U N I T D I V I S I O N B Y C C C W I N G A 1 8 E M E R G E N C Y ( E R ) 1 5 H O L D I N G ( A R ) 4 N U R S E R Y 1 6 P E D I A T R I C S 4 W I N G B ( 2 6 ) I C U 8 W O M E N S ’ W I N G ( 1 8 ) S A M E D A Y S U R G E R Y ( F L E X )

T ra n s p o r t a t io n S e rv ic e s

Standardized Work:Standardized Work:Alignment of ProceduresAlignment of Procedures

45 total existing Work Procedures for CC45 total existing Work Procedures for CC7 for CC procedures and policies7 for CC procedures and policiesRemaining are detailed guidelines for specific tasksRemaining are detailed guidelines for specific tasks

Align 7 Work Procedures to VSMAlign 7 Work Procedures to VSMRemove redundancies, including conflicting segmentsRemove redundancies, including conflicting segmentsOrganize and order methods and procedures to VSMOrganize and order methods and procedures to VSMAdded a detailed procedure for postAdded a detailed procedure for post--discharge orderdischarge order

Standardized Work: ResultsStandardized Work: Results

Keep Separate Work Procedures (AKeep Separate Work Procedures (A--F)F)Maintains original philosophies for Maintains original philosophies for categorization and separation of workcategorization and separation of work

Consolidates Seven Procedures into One Consolidates Seven Procedures into One Master ProcedureMaster Procedure

Orders and organizes work by Value StreamOrders and organizes work by Value StreamFinal procedure reduces 23 pages to 14 pagesFinal procedure reduces 23 pages to 14 pagesFurther CC consolidation possible in the futureFurther CC consolidation possible in the future

Existing Lean TechniquesExisting Lean Techniques

Visual Displays and ControlsVisual Displays and ControlsStatus BoardsStatus Boards

Patient BoardPatient BoardDischarge BoardDischarge Board

Binder Carousel of Medical RecordsBinder Carousel of Medical RecordsStatus Indicator DialStatus Indicator DialDischarge FlagDischarge Flag

Existing Lean TechniquesExisting Lean Techniques

ErrorError--ProofingProofingCC Coordinator Checks Continuity of CC Coordinator Checks Continuity of Care ReferralCare Referral

Continuous Improvements (CI)Continuous Improvements (CI)Performance Improvement DepartmentPerformance Improvement DepartmentCI teams meet twice per yearCI teams meet twice per year

Continuing Care ChecklistContinuing Care Checklist

Existing WastesExisting WastesDefectsDefectsOverOver--ProcessingProcessingInefficiency: Waste of CapacityInefficiency: Waste of Capacity

Lean Methods Applied to Eliminate WastesLean Methods Applied to Eliminate WastesErrorError--ProofingProofingStandardized WorkStandardized Work

MotionMotionWaitingWaiting

5S5SVisual ControlVisual Control

The The Continuing Continuing Care Care ChecklistChecklist

PATIENT INFORMATION Name:

Physician: Admit Date:

Discharge Date:

Wing A Pediatrics Emergency Wing B Holding Same Day Surgery ICU Wing C U

NIT

Nursery Other: __________

Complete N/A Demographic Face Sheet Mini Mental Multidisciplinary Form Level of Care I.D. Screen PASSR Continuity of Care (Interagency) Nursing Facility Referral SRS Waiver Maternity Early Discharge Alcohol / Drug Facilities

FO

RM

S

Psychiatric Transfer

Nursing Home Transfer Home w/ Skilled Nursing Home w/ Family Expired

DIS

POSI

TIO

N

Other: ______________

Blue Chip Blue Cross / Blue Shield Federal Medicare Medical Assistance Neighborhood Health Plan PHS Private Insurance Self Pay United Health Care / Metra Health

INSU

RA

NC

E

Other: __________________

Dis

cuss

ed O

ptio

ns

Dis

tribu

ted

Info

Arr

ange

d Se

rvic

e

Serv

ice

Dec

lined

Dis

cuss

ed O

ptio

ns

Dis

tribu

ted

Info

Arr

ange

d Se

rvic

e

Serv

ice

Dec

lined

Durable Medical Equipment Hearing & Speech Services Durable Power of Attorney Heating Assistance Meals on Wheels Home and Community Care Medical Assistance Home Equity Mortgage Mental Health Hospice Care

Nursing Homes Housing Substance Abuse Identification Cards Adoption Independent Living Adult Day Services Legal Services Advocacy Medicare Agencies for the Blind Medical Savings Alzheimer's Disease Nutrition Arthritis Foundation Ombudsman Case Management Prescription Programs Community Action Protective Services Community Diversity Publications Community Elder Specialists Respite for Children Dental Services Respite Care Early Response Senior Centers Education Opportunities Sr. Citizen Advocates Eldercare Locator Sr. Workforce Development Emergency Response Social Security Family Caregiver Supplemental Security Friendly Visiting Tax Information Geriatric Assessments Transportation

Health Centers Volunteers

SPE

CIA

L SE

RV

ICE

S

Health Insurance Counseling Other: _________________

Continuing Care Patient File BookContinuing Care Patient File Book

Existing WasteExisting WasteOverOver--ProcessingProcessingWaiting in Main Value StreamWaiting in Main Value Stream

Lean Methods Applied to Eliminate WastesLean Methods Applied to Eliminate WastesErrorError--ProofingProofingStandardized WorkStandardized Work

MotionMotionDefectsDefects

5S5SVisual ControlVisual Control

Continuing Care StatisticsContinuing Care Statistics

Performed by Administrative AssistantPerformed by Administrative AssistantExisting Method: ManualExisting Method: Manual

Search for DataSearch for DataManual data entryManual data entryManual calculations for totalsManual calculations for totalsSeparate MS Word documentSeparate MS Word documentPrint and distributePrint and distribute

Continuing Care StatisticsContinuing Care Statistics

Proposed Method: SemiProposed Method: Semi--automatedautomatedUse Checklist to avoid searching for dataUse Checklist to avoid searching for dataEase of data entryEase of data entry

CheckboxesCheckboxesDropDrop--downsdowns

Automatic Generation, Printing, and EmailingAutomatic Generation, Printing, and Emailing

Sample Form EntriesSample Form Entries

Sample Sample ReportReport

AccomplishmentsAccomplishments

Future State MapFuture State MapProjected time savingsProjected time savings

Standardized Work InstructionsStandardized Work InstructionsReduced from 23 to 14 pagesReduced from 23 to 14 pagesEliminated redundanciesEliminated redundanciesImproved training process for new hires or floatsImproved training process for new hires or floats

ChecklistChecklistCreated checklist that previously did not existCreated checklist that previously did not existProvided quality control mechanism for standard careProvided quality control mechanism for standard care


Patient File BooksPatient File BooksProvided hospital with a sample binder that all units Provided hospital with a sample binder that all units could adoptcould adoptOrganized all required forms into one locationOrganized all required forms into one locationSeparated forms for each room and patient into Separated forms for each room and patient into pocket folders to ensure qualitypocket folders to ensure quality

Data Reporting MethodData Reporting MethodProgrammed MS Access Database for Daily Entry of Programmed MS Access Database for Daily Entry of DischargesDischargesAutomated Monthly Report GenerationAutomated Monthly Report GenerationProjected Time Savings and Procedure SimplificationProjected Time Savings and Procedure Simplification


Successfully Introduced Lean HealthcareSuccessfully Introduced Lean HealthcareBenefits for training, reduced learning curves, patient Benefits for training, reduced learning curves, patient and employee satisfaction, improved quality, and and employee satisfaction, improved quality, and decreased length of staydecreased length of stay

Student Team Worked with Hospital StaffStudent Team Worked with Hospital StaffProvided perspective of outsidersProvided perspective of outsidersTranslated manufacturing principles to healthcareTranslated manufacturing principles to healthcareLow cost “consultants”Low cost “consultants”Students see applications of engineering to service Students see applications of engineering to service industries and alternate career optionsindustries and alternate career options

ConclusionsConclusions

FollowFollow--upupBinders are in use with the checklist as the first Binders are in use with the checklist as the first component in each patient’s sectioncomponent in each patient’s sectionDatabase programming was further tailored by the Database programming was further tailored by the hospital’s inhospital’s in--house programmers and is now in usehouse programmers and is now in useImproved procedures are now part of the hospital’s Improved procedures are now part of the hospital’s accreditation processaccreditation process

AcknowledgementsAcknowledgementsThank you to the nurses and administrators at the Thank you to the nurses and administrators at the New England hospital who shared their time and New England hospital who shared their time and opened their facility for this student projectopened their facility for this student project

ReferencesReferences[1] Leah L Curtin. 1997. Lean, mean and stupid! [1] Leah L Curtin. 1997. Lean, mean and stupid! Nursing Nursing

ManagementManagement. 28 (5) (May): 7. 28 (5) (May): 7--9.9.[2] [2] LaubrassLaubrass Inc. Timely Care. Inc. Timely Care.

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