Don't Lose Patients

7/27/2019 Don't Lose Patients

1/9


2/9

HEALTHCARE

Hybrid approach helpshospital streamlineicey processby Todd Creasy and Sarah Ramey

CLINCH VALLEY MEDICALCenter-afor-prot, 175-bed h ospital o perating in w estern V irginia and pa rt of a hea lthcareorganization with operation s in 18 states has been und ertakinglean Six Sigma initiatives for ab out th ree y ears.

During its continuous improvement ef-forts, the hospital employed the principlesof 6T0C'a combination of lean Six Sig-ma and the theory of constraints (TOC)^ inwhich organizations resolve process flowconstraints or bottlenecks in a service-delivery system with lean and Six Sigmatools.The hospital's senior managem ent teamdecided to focus on the preadmission test-ing (PAT) process as pa rt of the hospital'scontinuous improvement initiative. PATevaluates, assesses, educates, and pre-pares patients and families for successfuland safe h ospital expe riences. Along withthe emergency department, these servicesare a corne rstone to hospital revenue.PAT is the front door to a patient'sexperience in any hospital and providespatients their first impression of thehospital and services rendered. Nearly

all outpatient procedures are consideredelective surgery in tha t patients can s electthe hospital organization at which theywish to receive the surgical procedure.A poor PAT experience can send thepotential patient elsewhere.PAT is also a vital part of the processfor operating room (OR)clinicians. During PAT,all of a patient's pertinentinformation is collectedmedical history, currentmedications, lab resultsand electrocardiograms.Without a stream lined pro -cess, one or more of theseaspects can be inadver-tently omitted. This omis-sion can result in delayedsurgery or cancellation,leading to lost revenue.

In 50 W ordsOr Less iciencies iney process, a hospital com bin edan Six Sigma and the theory ofconstra ints to iden t ify and el im i-nate b ottlenecks.As a result, the hospital cut wa itt im e for its patients b y 70% andel im inated the m ain cause of cus-tom ers seeking other providers.


3/9

Hearing voicesThe PAT proc ess at Clinch Valley Medical Center b eginswith the patient 's physician contacting the hospitaland scheduling a surgery appointment. It concludeswith the patient arriving home from the hospital afterhaving health and prescription reviews, proceduresscheduled, and any necessary X-rays and laboratorytests conducted.

The list of stake hold ers for the PAT pro ces s in-cludes patients, physicians, nu ises, PAT assessors, labtechnicians, OR schedulers, the medical records de-partmen t, hospital admissions and other employees inthe phy sician's office.

Based on the fact that customer experience can en-hance an organization's revenue and margins and canhelp organizations differentiate themselves through to-tal customer experience,^ voice of the customer (VOC)data were collected from these PAT stakeholders. It wasdetemun ed the proce ss had six areas of concern:1. Pat ient educat ion. Patients didn't understand

their financial obligations and weren't beingeducated about the preadmission process andultimate outcome.

2 . Effective communication. Throughout theprocess , there wasn't effective comm unication thatincluded the ex ternal physician, PAT nurse, hospitalcoordinators and patient.

3 . Patient scheduling. Patients were visiting thehospital in very erratic patterns and not in aconsistent flow.

4. Waiting. Patients were experiencing excessive waittimes, and their time in the hospital was not beingmanaged w ell.

5. Documentation. Docimients were being reprodu cedtwo and three times for various departments in thehospital.6 . Bott lenecks . The process produced excessiveamounts of work-in-process information backupsand patient delays.As a result of these problem areas, the PAT process

was determined to be time-consuming and a potentialcontributor to pa tient dissatisfaction.Process ex piorationWith three m onths to improve the proce ss, the hospitalcollected a sample size of 62 consecutive patient expe-riences during one week. The PAT proce ss had an aver-age unnecessary p atient wait time of about 20 minutes

(standard deviation of about 18 minutes), with sowaits exceeding an hour. The goal of the PAT prowas to reduce patient wait time by 30%.

The improvement drive continued with the consttion of a high-level process flow chart that includesuppliers, inputs, processes, outputs and custom(SIPOC) diagram (Table 1). The critical-to-quality awithin the SIPOC dealt primarily with patient e ducatpre-screening accuracy, stakeholder communicaand scheduling of the surgical procedure.

The column in the table marked "Process" affordhigh-level view of the PAT proc edu re. The rule of thufor SIPOCs when initially considering the procolumn is not to excee d four to seven horizontal levThis type of process documenting activity can leada better understanding of the process and idenpossible improvement alternatives.

With a room full of PAT stakeholders following 6T0C principles, the process was dissected at a hlevel (Figure 1, p. 46). A pro ces s flow chart w as ated indicating natural process break po ints and whGreen Belt (GB) team would attend to that portioimprovement needs.

When this process was mapped, the stakeholdwere aske d to identify bottlenec ks within the procThis is where TOC and its ve basic tenets prouseful:1. Identify the bottleneck.2. Exploit the bottleneck (get the most out of it).3. Subordinate the system to the speed of

bottleneck's flow.4. Alleviate the bottleneck (make significant chan

that reduce or eliminate the bottleneck ).5. Begin identifying more bottlenecks.

The bottlenecks were identified as: Step 6Surgeo n's office informing patie nt of date and surgery information. Step 8Patient time in waiting room with beep Step 10Pre-registration and the collection of

tient information or payment. Step 15Start of patien t assessm ent. Step s 18-19Direction and edu cat ion regEir

laboratory test and X-rays.This process is similir to the explanation of hea

care as a chain of handoffs.' ' Bottlenecks were conered along with natural breaks in the process to ption out the smaller segments that comprise the laPAT process.


4/9

HEALTHCARE

Before the groups of stakeholders were releasedand GBs formally assigned to each section of the pro-cess, the team explored early improvement ideas byusing a functional deployment matrix (FDM). Similarto a prioritization matrix,' ' an FDM is a quantitativemethod for brainstonning necessary inputs and de-sired outputs using a simple, two-dimensional format.

Table 2 (p. 47) lists the key process input variablesan d key process output variables as determined by thePAT stakeholders who constructed an FDM during anall-day m eeting.Improvement initiativesThe PAT improvement team pursued bottleneckexploitation or elimination using lean Six Sigma toolsand followed these seven improvement steps:1. Three paper-based forms each containing two pages

and one computer-based form were combined into

a single computer-b ased form. This eliminated w orkredundancy by the PAT nurse and also sped up theprocess time for each patient, thus reducing totaltime in the PAT system.

2. Because there was an information gap between thelocal, referring clinics and the hospital's internalpractices and processes, the patient informationbooklet was revised and reformatted for use withsurrounding clinics. Based on cUnician VOC, acommunication guide was constructed to enableoffice administrators and clinicians to betterunderstand the hospital 's internal process needsand to educate patients.

3. The delivery pro cess b y which local cUnics forwardpatient charts to the hospital was changed. Formerly,the patient was responsible for delivering the chartto the hospital, which resulted in administrative de-lays. By using VOC from one of the clinics, this chart

Suppiiers, inputs, processes, outputs and customers / TABLESupplierPhysicianPatient

PhysicianPatient

PatientSchedulerPhysician'soffice

PhysicianPatient

PhysicianPatientOR sc hedulerPatientOR Sc heduler

1 . Physician.2. Patient.3. A i lmen t4. Doctor's office -administrat ion.

1 . Physician.2. Patient.3 . A i lmen t4. Physician's office -administrat ion.1 . Patient2. PAT schedu le.

ProcessPhysician schedulessurgery appointment.

OR schedulerschedules PATappointment.

1 . Patient2. Correct physicianorders.3. Consent form .1 . Patient2. Physician orders(via PAT nurse ).1 . Patient.2. OR schedule.

Patient arrivesat hospital andregisters.

Patient is assessed(EKG and H&P).

Patient is transferredfor ordered tests(labs or X-rays).Patient leavesdischarged withsurgery date/time.

1. Surgery date established. 1 . Patient2. Instruction booklet is given. 2. CVMC3. Scheduler.

1 . Patient2. Physician.3. PAT nurse.

1 . Patient.2. PAT nurs e.3. H ospital.4. OB.

1 . Patient.2. OPS.3. OB.4. Anesthesia.1 . Patient.2. Laboratory.3. X -ray.1 . Patient2. OPS an d OB.

I.PAT date/time.-!2. Process educaticin.

1 . Patient is pre-registered.2. Patient pays money3. Insurance inform ation isacquired.4. Patient receivesdirections.1 . Historysurgery/patienteducation completed.2. EKGs com pleted.3. Anesthesia assessm entcompleted.1 . Copy to patient (lab andX-ray).2. Patient education.1 . Schedule surgery dateand t ime.2. Patient education.

CT Q1 . Date - correc t.2. Instruction - correct andconcise.3. Surgery - correc t

procedure.1 . Patient know s PAT date/t ime.2. Patient knows process.

1 . Patient knows whereto go.2. PAT nurse notified intimely manner.3. Payment to CVMC.4. Correct insurancecompany information.1 . Correct patient history.2. Correct patienteducation.3. Correct chart to OPS.Timely, completed,accurate and obtained/scanned.Correct patientinformation. m

Q = critical to quality OB = obstetricsChurc h Valley Medica l Center OPS = opera tionsKG = electrocardiogram OR = operating room= history and physical PAT = preadmission testing


5/9

PAT pre-improvem ent process fiow ciiar t / FIGURE 11. Surgeon's off ice

calls OR schedulingwith possible date.2. OR scheduler

checi


6/9

HEALTHCARE

Functional deployment matrix / TABLE 2Key processoutput variable(KPOV) *Patient (customer)priority Rank *

Correct ,complete Friendiyinformation PAT patientand properiy serv ice / Wait ing Compieteeducation scheduied dipiomatic t ime assessment

Key process inputvariable (KPIV) *1 . Physician office =has in format ion.2. Information and processis correct .3. Pat ient knows where to go . '4 . Standard operat ingprocedure.5. Communicat ion tool .6. Employee scheduling.* KPiVs, KPOVs, rankings and non-calculated numbers w ere a cquired from stakeholder opinions in all day team meeting.PAT = preadm ission testing

138 ' '2955

^ H Calculated| H rank20726 425 930524 723 0

Calculatepercentrank13.6917 .4617 .1320.1716.3415.21

tient tracking system was developed to serve as asignaling device. This system alerts the nurses inoutpatient surgery of a bottleneck in the PAT area.After being notified, a nurse arrives to alleviate thebottleneck and associated stress. Applying humanresources in times of peak patient inflow exploitsthe bottleneck's cap acity for service, thus reducingpatient wait times.Removing proce ss steps or combining steps for syner-

gy's sake are a tenet of lean. The new proc ess has 17 steps(Figure 2, p. 48) compared w ith the former, which had 20.

More importantly, a post-improvement sample sizeof 61 consecutive patients during the course of oneweektwo months after the project was initiated andimprovements beganrevealed the average patientwait time dropped from abo ut 20minutes to just u ndersix minutes, a reduction of around 70%.

In addition, the standard deviation narrowed from18.9 minutes to just un der 6.3 minutes, a 67% reduction.

he effect of these process changes is illustrated inFigures 3 (p. 48) and 4 (p . 49) in the form of box plots.Proving improvementPractitioners of process improvement are sometimesat the outcome s resulting from their labors.

They wonder whether the performance after the im-provement change is truly different than the baselinedata or is simply a proc ess operating on a good day.The answer hes with a two-sample t-test," whichanalyzes data under the assumption the populationsfrom which the samples are drawn are not different(the statistical difference between the population'smean is zero), and therefore the process hasn'tchanged statistically.

A p-value of g reater than 5% (assuming a 95%significance level) indicates the comparator samplesmay actually be from the same populationhence nosigniflcant change in the process. P-values of less than5%, however, are indicative of the data sets not beingtaken from the same population and suggest the post-pro ces s improvem ent sample is significantly different.

This test quantitatively illustrates what all im-provement pract i t ioners desire to know: the processhas improved, and the time and energy invested werenot in vain.

After examining the results of the two-sample t-test.Clinch Valley Medical Center disco vered t he p-value w as0 (confidence interval for mean difference = 8.52,18.61).A test of equal variance (hypothesi2ing the variationswere the same) provided a p-value of 0 for two other


7/9

PAT post-improvement process fiow ch art / FIGURE 21 . Surgeon's officecalls OR sched ulingwith proposed date.

2. OR schedulerchecks date andparties reachagreement.

i. Registrar enters patientinformation into hospitalsystem:' Contact information. Insurance company.' Family.' Collects payment.

3. OR sched uler. sched ules PAT _and surgeryIn hospital system .

7. Patient arrives athospital at designatedPAT tim e and goesdirectly to registration.

4. OR sched ulerinforms surgeon'soffice of PAT da te.5, Surgeon's office informs patient of 'PAT da te.

9. Registration escortspatient to PAT wa itingroom and takes chartto PAT nurse.

1 6. Radiologytest areperformed.

1 0. PAT nursecalls patient intoexam room.

15. X-ray technician- collects patient


8/9

HEALTHCARE

uD O

PATwai tt i m e -after

PAT w aitt i m e - -before

(Sos ;

PAT w aitt ime - -after

PAT w aitt i m e - -before

PAT = preadmission testingStDev = standard deviation

open to suggestions or pro-cess modifications. He took

ride in his responsibilitiesnd had difficulty seeing theeed for improvement. Focus-ng on tlie process rather than

3 . Good data are key.

work ta sks. One

4 . Get your hands dirty.

L

rom the team accom-e PAT nurse and collected process wait-time

5. See the results quickly. Success breeds mo-s often the case w ith proce sses that have

t process, patient w ait-time data w ere col-

data proved to be invaluable.In the future, hospital reimbursements from

ore price-centric.This will force hospital administrators to focus in-

Test for equal variances for times / FIGURE 4F-testTest statistic

p-value0. 11

0Levene's testTest statistic 29.77P-value 0

10 15 2095 % Bonferroni confidence intervals for stDevs 25

80

administrators in their quest to deliver a better health-care model, which provides a better patient experienceand improves quality of care. Q PR E F E R E N C E S1. Todd Creasy, "Pyramid Power." QualityProgress, June 2009, pp. 40-45.2. Jeff Cox and Eliyahu M. Goldratt, The Goal:A Process of Ongoing Improve-ment, North River Press, 1986.

3. John Goodm an. "Taking the W heel," Quality Progress, February 2012, pp.42-47.

4. Edward Chapiin, "Reengineering in Heaith Care," QualityProgress, October1996, pp. 105-109.5. Jack ReVeile, "Making the Conne ction," QuaiityProgress, July 2010, pp. 36-44.6. David Freedman, Roger Purves and Robert Pisani, Statistics, third edition,

WW Norton and Co., 1998, pp. 127-129.

TQDD CREASY is an associate professor at WesternCarolina University in Cullowhee, NC, anda consuitant.He earned a doctorate in management from CaseWestern Reserve University in Cleveland. Ah ASQmember. Creasy is a certified Six Sigma Black Beit.

SARAH RAMEY is a clinicai pharmacist at Oinch ValleyMedical Center in Richlahds, VA . She earned a doctor-ate ih pharmacy from Clinch Valley Medical Center.


9/9

Copyright of Quality Progress is the property of American Society for Quality, Inc. and its content may not be

copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written

permission. However, users may print, download, or email articles for individual use.

Don't Lose Patients

Documents

Transcript of Don't Lose Patients