Innovations in Helping All Generations of Veterans

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Innovations in Helping All Generations of Veterans

• Searching for the Benchmark
• Mike Davies, MD FACP
• Chief of Staff VA Black Hills

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Searching for the Benchmark

• Introduction
• The paradox of innovation.
• Where will innovations come from?
• How to think about innovations.
• Do it yourself
• Challenge

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The Paradox of Innovation
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A Model for Improvement
What is our aim? How will we know a
change is an improvement? What changes can we
make to make an improvement?
Plan the test the experiment
Act differently the next time
PLAN
ACT
DO
STUDY
Assess the results
Execute it
Langley, Nolan, et.al. The Improvement Guide
A Practical Approach to Enhancing
Organizational Performance. Jossey-Bass. San
Francisco, CA. 1996
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The unofficial version!

• Hunch
• What could be happening here?
• Test
• Lets try something different
• Reflect
• How did it work?
• Change
• Should we keep doing it?

From Sarah Frasier
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How Toyota Thinks

• Innovations dont (necessarily) come from the big
  things..the come from small things
• The people who DO the work must TRANSFORM the
  work
• Experiment widely to find the best
• Once the best is found, STANDARDIZATION is a good
  thing

Feel Free to do It just this way Until a proven
better Way is found
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How Do We Think About Innovations?
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Flow Through the Office
Check-in to Nurse
Dr. in to Dr. out
Nurse to Room
Check-out to leave
Synchronization Point
System
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How Processes Support Flow
Check-in to Nurse
Dr. in to Dr. out
Check-out to leave
Nurse to Room
Process
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Define the Work (Examples of Common Processes)

• Registration
• Billing
• Phones
• Authorization
• Medication monitoring
• Scheduling
• Referrals

• Messages
• Refills
• Rooming
• Advice
• Teaching
• Order entry
• Care under protocol

Organize Better
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Define the Work 2 (Examples of More Processes)

• View Alerts
• Communication of results
• Communication of consult request results
• Communication of team notes
• Progress note design

• E-health care
• Telephone care documentation
• Access to medical information resources
• Nurse chronic disease and prevention care
• Admit/transfer

Organize Better
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How Tasks Support Processes
Specialist Referral Process
Make Appointment
Tasks
Give Directions
Check-in to Nurse
Dr. in to Dr. out
Check-out to leave
Nurse to Room
Task
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How Tasks Support ProcessesSpecialist Referral
Process
Task Call to make appointment
Task Give directions for specialist
Task
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Details Matter

• Just ask anyone whos spent the night in a tent
  with a mosquito

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Step 1 Lay Shirt Face Down
Details..
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Step 2 Fold in side
Details..
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Step 3 Fold in Other Side
Details..
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Step 4 Fold the bottom half way up
Details..
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Flowchart Example
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T-Shirt Folding Innovation Video
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Flowchart Example
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Do Seconds Matter?
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Importance of the Red Zone

• What we sell is a relationship
• Red zone is where relationship is established and
  enhanced
• Red zone is what patients come for
• Red zone is where value is delivered
• Number of red zones determine productivity
• Effectiveness of red zones determine quality
• In a healthy clinic, the red zone should be the
  constraint

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Perfect Flow
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The Role of Variation
Non-standard processes lead to variation!
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Thought Experiment

• If 6 slots per ½ day session
• Then 2592 slots/doc/year
• 8 visit slots per ½ day session
• Work 4.5 days/week and 48 weeks per year (216
  days per year)
• 3456 appointment slots/doc/year
• If 10 visit slots per ½ day session
• Then 4320 appointment slots/doc/year

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Inside the Red Zone

• Length of the red zone governs supply
• Red Zone often a black box
• What happens inside the red zone?

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Drug Ordering Task Example Worst Case Scenario
Order Completed
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Start to type name of drug
Choose New Medication
Click on appropriate drug
Complete all the necessary fields
Click on Accept Order
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Process from Decide to Accept
Click Action Click New Med
Click Med Tab
Decide
Type Flucon
Click Schedule Type BID
Days Supply Type 30
Click Dosage
Click PRN
Quantity Type 60
Refills Type 2
Comments 0-16 Keystrokes
Select Pickup
Pt. Instructions
Accept
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Some Hang-ups

• Specify a location? (13 keystrokes)
• Formulary? (delay 1-3 minutes?)
• Do I know quantity? (delay 1-3 min?)
• Negotiate pickup of meds (Pt. decision)
• Miss fields? (min. 4 keystrokes)
• Arrangement of keyboard/mouse
• Use of tab key?
• Keyboard skill level
• Speed of network/computer
• Speed of order checks

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Best Case Decide to Accept

• 12 steps
• 27 to 44 keystrokes
• 52, 46, and 68 seconds 55 seconds
• Could be 5 minutes or more if hang-ups

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Drug Ordering Task Example Best Case Scenario
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Innovation Decide to Accept
Choose Categorized Medication Menu
Choose Dermatology Medications
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Choose the dermatology medication you want
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Medication is completely filled out. The provider
can edit any section or Accept Order.
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Process from Decide to Accept
Click Orders Tab
Click out-patient Meds
Decide
Click Meds
Click Flucinolone
Click Derm..
Accept
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Best Case Decide to Accept with Process Redesign

• 5 steps
• 6 to 23 keystrokes
• 25, 23, and 30 seconds 26 seconds

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Implications of Innovation
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Challenge

• Pick a process that bugs you
• Team
• Those involved with a process should change it
• Aim
• Focus on delay (keystrokes, steps, time)
• Measure
• Measure timeliness, reliability
• Quality
• Change
• Tests of change PDSA OR Hunch, Test, Reflect,
  Change

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What to pick?

• Medication ordering process
• Progress note documentation
• Chronic Disease and Prevention documentation
• Lab results notification process

• Anything slated for new development and medium to
  low on list
• Computer sign on process
• Speed of computer

• Things we may not control

• Things we control

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Outcomes

• Nothing is more important than the goal
• Goal MUST be measurable
• Team is engaged
• Team teaches others
• System develops benchmarked processes
• System has efficiency measures to guide
  development
• We support and teach each other

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Thanks to John Reiffenberger Becky Davies Dr.
John Kenect