Lean in Healthcare · Lean aims to take out waste and increase value add in healthcare processes In...

© Copyright Kelvin Loh, Jan 2011

Lean in Healthcare

Sustaining and Spreading the Gains

Dr Kelvin LohMBBS, MBA


Agenda

Quick Recap: Objectives of Lean in Healthcare

A VSM Journey – and what it means in practice

Sustaining and spreading the gains- The problem- Coordination and prioritisation- Measurement

A few impactful ideas


Diagnosis Treatment & Advice

Without Delays, Without Mistakes

Objectives


COST

ACCESS

(more can get it)

QUALITY

(what patients really want)

Objectives for the System


Objectives:

Safety Quality Delivery Cost Morale (SQDCM)

Achieving

continuous flow

Possible Tools:

• Patient Centred Teams

• Quick Setup

• Get rid of waste, bring

cycle time to takt time

• Workload Leveling

• Match Supply to Demand

• Pull systems

Built In Quality

Possible Tools:

• Error Proofing

• Visible controls to identify

errors

• Andon

Foundation of Operational Stability

Training, Standard Work, Genchi gembutsu,

Value Stream Mapping, Visual Management (5S),

Proactively Care for Resources

Continuous Improvement

by working in teams

(PDSA)


Approach by Value Stream

Discharge,

Billing

Admission

(Call Centres, Front Office,

Business Office, etc)

A&E

Nursing,

Wards

Clinical Depts

OT,

Endoscopy,

Specialised Services eg

CVL

Allied Health Svs eg Lab, Radiology, Pharmacy

Support Services eg BME, F&B

Eg CABG

Eg Total Knee Replacement

Improvement Activity


VSM Journey - Example


Total Knee Replacement VSM


Reduce Waste in

pre-op process Improved CPM

coordination

Patient

transfer for

X-Ray

Planned

discharge

Lab, X-

Ray and

ECG

Tests

PT:130

DT:0

Total:130

Admission

PT:60

DT:0

Total:60

Pre-Op

Prep in

Ward

PT:50

DT:20

Total:70

Pre-Op

Prep in

OR

PT:45

DT:20

Total:65

Operation

PT:180

DT:30

Total:210

Post-Op

Care

(5 Days)

PT:510

DT:770

Total:1280

Patient

to Lobby

PT:5

DT:15

Total:20

Discharge

Prep

PT:60

DT:0

Total:60

Bill

Payment

PT:45

DT:5

Total:50

Booking

PT:15

DT:0

Total:15

Pre-Admission Pre-Operation Preparation Post-Op

Care

Operation Discharge

ININ

IN

Total Knee Replacement VSM


Current State of Pain Assessment

Pain Flow Sheet is raised for every patient

despite pain score

Total: 19 fields

New State of Pain Assessment

Pain Score incorporated into the New Clinical

Chart ; Pain Flow Sheet raised only for pain

score 3 and above

Total: 1 field

Streamlining Pain Assessment Process

95% reduction in fields per entry (pain score below 3)

65% reduction in fields per case

Time savings per case = 23.5 mins


Spreading the Gains from VSM


Spreading the Gains

Discharge,

Billing

Admission



A&E

Nursing,

Wards

Clinical Depts

OT,

Endoscopy,


CVL




Improve, Document, Spread

Standard Work Standard Work


But as journey goes forward…


Value Stream (VS)

Approach

(Large, cross

functional projects)

2) Key Tools 5S,

Standard work

(Small, intra-dept

projects)

Top Down (VSM) and Bottom Up Approach


ProblemsDischarge,

Billing

Admission



A&E

Nursing,

Wards

Clinical Depts

OT,

Endoscopy,


CVL




Eg CABG

Eg: Stroke Patient

1. Lack

Momentum in

same VSM

3. Too many pilots

Repeating / Duplicate Projects

2. Unable

to spread

successful

pilot

2. Unable

to spread

successful

pilot


Spreading the gains:

Coordination & Prioritisation


Drivers / CoordinatorsDischarge,

Billing

Admission



A&E

Nursing,

Wards

Clinical Depts

OT,

Endoscopy,


CVL



Eg Total Knee Replacement1. VSM DRIVER

2.

PROCESS

OWNER

3.OVERALL COORDINATING

‘LEAN COUNCIL / QUALITY COUNCIL’


Lean Council / Quality Council

Terms of Reference

•Keep track of all VSM and pilot projects status•Oversee change management process •Prioritise activity.

•Create Model VSMs and follow through with all projects•Pick pilot projects for spread across different VSM / different units

•Set timelines•Set measures•Track measures•Hold VSM leaders, Unit Leaders accountable for implementation

Members:Medical Director/CEO and all key leaders


Change Management

Common Problems

1. We don’t have any problems

2. ‘Loss of face’ because the previous process was designed by someone being asked to change

3. Our ward / unit is different- We don’t have the same skills- Our environment is not the same- Our patients are different (more complex)- Our process is different

Involvement- junior staff- middle managers- top managers

Genuinely take feedback

Be persistent


Prioritisation Matrix!(Example)


Measuring the Journey


COST

ACCESS

(more can get it)

QUALITY

(what patients really want)

The ‘Iron’ Triangle..can be broken through lean thinking..How do we measure this?


Track Value Drivers for each VSM (eg TKR VSM)Consultation Waiting Time (EMD P2) - 50th Percentile

0

5

10

15

20

25

30

35

40

45

50

Months

Min

ute

s

P2 Target 20 20 20 20 20 20 20 20 20

P2 46 44 32 31 24 25 24 31 23

Apr May Jun Jul Aug Sep Oct Nov Dec

PDCA 1 PDCA 2 PDCA 3

Eg:

- % rework in consent forms

- Turnaround time for pre-op prep

- ALOS



Run charts of aggregate KPIs (that measure value) at organisational levelConsultation Waiting Time (EMD P2) - 50th Percentile

0

5

10

15

20

25

30

35

40

45

50

Months

Min

ute

s

P2 Target 20 20 20 20 20 20 20 20 20

P2 46 44 32 31 24 25 24 31 23

Apr May Jun Jul Aug Sep Oct Nov Dec

Eg:

- S: Adverse event rate

- Q: Patient satisfaction score

- D: Waiting time for appointment

- C: Labour productivity

- M: Employee satisfaction score



A few key impactful ideas


1. Workload Levelling

AM PMMorning tsunami in hospitals =>-Long wait-Lower quality care because of rushing-Potential safety issues-Stress for staff


1. Workload Levelling

Possible ideas

•Appointment scheduling by date and time•If come early, will have to wait till appointed time•Non-fasting patients in pm•In town patients pm, patients from out of town am•Share clinic space for different disciplines eg orthopaedic patients pm, medicine patients am•Segregate ward round timing eg Medicine inpatients pm, orthopaedic inpatients am•? Incentivising through differential pricing


v

Old Hospital Design…

2. Cell concept (Decentralise)



Rows No 1-34?


C1 C6 C5

C3

C7C2C4

Reg Consult

Lab Test

X-ray

PharmacyBilling

Benefits :-

1. Patient / Customer- Centric (better care coordination)

2. Cuts down muda of motion

3. Encourages teamwork and ownership:• Equal productivity at any volume

• Better communication

• Faster feedback

• Support and assistance

• Easier problem solving

E.g. Orthopaedic

Centre / Clinic / Floor

Treatment



Neurology

and Spine

Clinic

Xray, CT, MRI,

PT, OT

ECG, Lung

Function Test,

Treadmill Test

Cardiac and

Pulmonary

Clinics

Ortho

Outpatient

Clinic

Xray, PT, OT


3. Provide care at lowest possible resource intensity

Saohai Hospital Primary Care Unit

Health Education

FBS, Hba1c testing

Lower need for all patients in community to make far visits to hospital

Lower patient load at hospital => Shorter waiting time, doctor can spend more quality time with sicker patients

Qn: Is each healthcare service that we provide provided with the lowest possible resource intensity?

Eg: Integration between Hospital and Community


4. Clinical Value, Teaching Value, Research Value

Clinical

Value

Teaching

Value

Research

Value


ConclusionLean aims to take out waste and increase value add in healthcare processes

In doing so we should be able to provide greater access, higher quality and lower cost

Sustaining and spreading the gains requires us to:

- Have coordinators deconflict projects and drive adoption across system. Lean Quality Council is a must

- Prioritise which projects to spread using an impact matrix- Not to underestimate change management required- Measure value KPIs – SQDCM

A few impactful ideas- Workload levelling- Cell-centred concept (decentralise)- Provide care at lowest possible resource intensity- Clinical value, Research value, Teaching value

Lean in Healthcare · Lean aims to take out waste and increase value add in healthcare processes In...

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