A Case Study in Improving Patient Flow

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A Case Study in Improving Patient Flow
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What is Lean?

• The art of producing and delivering goods and
  services that deliver maximum value to the
  customer with minimal waste in the process. 
• Doing the right things (as defined by your
  customer) and doing them better, faster, and
  cheaper.
• A process management philosophy
• Derived in large part from the Toyota Production
  System (TPS)
• Later successfully adapted in a wide variety of
  business settings manufacturing, maintenance
  repair, healthcare, professional services, office
  processes

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Growth and Spread of Lean
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Growth and Spread of Lean
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Lean Principles

• Define value in the customers terms.
• Understand what it is that your customer values
  and is willing to pay for.
• Map and define the value stream. 
• The series of actions that collectively build
  value for the customer is the value stream. 
  Identify and eliminate non-value added
  activities.
• Make value flow. 
• Strive to implement a process in which
  value-creating activities can move quickly,
  seamlessly, with minimal effort and without
  backtracking or rework.
• Pull from later processes to earlier ones. 
• Have the cadence, or rhythm of activity, driven
  by being pulled from the customer at the end of
  the process, rather than pushed by the producer
  or supplier to the process.
• Continually strive for perfection.
• Constantly learn and improve.

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• Waiting- Time spent waiting on items required to
  complete a task (i.e., Information, supplies,
  etc.)
• Unnecessary Motion- Any motion that does not add
  value to a product or service.
• Processing- Effort and time spent processing that
  is not adding value
• Inventory- Waiting for processing
• Moving items- Transporting by mail, cart, or foot
  travel
• Making too much -Producing more than the ultimate
  customer requires
• Fixing defects- Time spent repairing or reworking
• Under-utilised intellect- Failure to use peoples
  creativity and intelligence

Waste is anything that the customer is not
willing to pay for
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St. Jamess Lean Event

• A workshop was held in January 2009
• Target improvements in the Haematology / Oncology
  Daycare Centre (HODC) unit
• Improve patient flow and reduce waiting times
• Increase capacity without adding resources
  (headcount, area, capital)
• Reduce costs
• Cross-functional team identified 34 improvements
  and designed new processes to improve patient
  flow and units performance

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The Psychology of Queues

• Unoccupied time feels longer than occupied time.
• Pre-process waits feel longer than in-process
  waits.
• Anxiety makes waits seem longer.
• Uncertain waits seem longer than known, finite
  waits.
• Unfair waits are longer than equitable waits.
• The more valuable the service, the longer the
  customer is willing to wait.
• Solo waits feel longer than group waits.

Source David Maister, The Psychology of Waiting
Lines
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As Is Process Oncology

• Typical path (treatment with pre-made drugs)
  through this process takes 7 hours 50 minutes
• Patient queuing/idle time is 3 hours 10 minutes
  (40 of total)
• More than 3.5 hours elapses from the time the
  patient arrives until chemotherapy begins, 92 of
  which is spend queuing or waiting
• Patients receiving no intervention (consultation
  only) take 2 hours 15 minutes, 79 of which is
  queuing or waiting

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Problems Issues Registration
The team identified problems and issues that
arise in the current process, grouped by major
steps in the process. The following were
identified in reception and scheduling

• Overbooking of patients and simultaneous bookings
• Medical charts removed from unit without
  permission or record
• No system for dealing with unscheduled patients
  (walk ins)
• Patient arriving at wrong appointment time
• Major interruptions
• Appropriate bloods not ordered
• Demand led service with no cap on activity

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Suggested Actions Reception
The team brainstormed actions and changes that
would help address the identified problems. The
following were agreed in the area of reception
and scheduling
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To Be Processes

• The team next identified new ways of structuring
  the treatment process to improve patient flow
• The concept of takt time (process pace or
  rhythm) was introduced
• Takt time was calculated at 6 minutes/process
  step and activities were grouped into 6 minute
  units of standard work
• Four separate processes were defined
• Same-day treatment (similar to As Is process)
• Two-day treatment (optional to the patient) with
  blood submitted on day prior
• Haematology direct treatment, with no lab
  analysis required
• Clinic only, with blood testing and doctor
  consultation but no treatment administered

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Clinic Process (Reception, Phlebotomy,
Consultation)
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To Be Process Same Day Treatment

• Typical path (treatment with pre-compounded
  drugs) should take 5.5 hours (30 reduction
  compared to As Is)
• Patient queuing/idle time is 62 minutes (19 of
  total, 67 reduction compared to As Is)
• Also planned new optional 2 day process for
  some patients

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To Be Process Two Day Treatment

• Process should take patient lt 15 minutes on first
  day, 4.5 hours on second day (for 4 hour
  treatment)
• Total queuing/idle time lt 10 minutes (95
  reduction compared to As Is process, 85 less
  than To Be same day process)
• Dramatic reduction in waiting offsets
  inconvenience of making two visits
• Medium-term goal is to allow off-site submission
  of blood sample (GP, regional hospital, etc.)
• Initial target is for 12 patients/day to opt for
  two day treatment (1/3 of total treatments)

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Follow Up Steps

• Internal communications
• Action Plans and follow up
• 34 Individual action items (80 are small, simple
  improvements that take six weeks or less)
• Evaluate physical layout and possible
  improvements
• Field trip to an industry reference site
• Follow on lean activities
• Visual Controls
• 5S
• Broader staff training
• Waiting time audit
• Patient satisfaction survey

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Learn From Others Best Practices

• Manufacturing
• Visual Controls / 5S
• Flow and standard work techniques
• Aviation
• Checklists
• Crew Resource Management
• Other Healthcare Organisations

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• Patient flow
• Operating theatre turnover
• Scheduling
• Workplace disorganisation
• Medical records
• Inventory control
• Equipment availability
• Bed management
• Shift change processes

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Early Successes

• Less crowding, shorter waiting times
• Pharmacy process 75 reduction in unplanned
  chemotherapy, increased productivity, Minimised
  patient risk
• Improved employee morale teamwork
• All levels and functions working together to
  improve
• Clinics finishing on time
• Cost savings
• Reduced overtime
• Improved clinical codingbetter data on actual
  treatments delivered, more accurate funding
  allocation
• Labour utilisation and throughput capacity
• Reduced drug wastage and increased productivity
  in manufacturing unit

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Audit of Waiting Times

• Results being analysedto be presented at the
  conference

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5S Office Event

• 5S sort, set in order, shine, standardize,
  sustain
• The foundation of a visual workplace
• Challenges
• Staff perception that it is overkill
• Maintaining an agreed level of order
• Sustaining impetus after preliminary event
• Changing mindsets to think 5S
• Finding a local champion on the shop floor

Before
After
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Employee Satisfaction

• Chief II Pharmacist (Clinical) - Planned
  Chemotherapy is good Chemotherapy, the new
  appointment system has resulted in a significant
  reduction in unplanned chemotherapy
• Chief II Pharmacist (Chemotherapy manufacturing)
  The scheduled collection times for
  chemotherapy has changed the way we work to a
  great extent. It has allowed us to structure our
  manufacturing around delivery times resulting in
  increase productivity and reduced wastage
• Admin Clerical - Not racing against the clock
  all the time
• Less stressed, more time to concentrate on the
  task in hand
• Nursing - Patients are now arriving in the
  dayward at their appointed time
• I think we could treat more patients with the
  staff we have when this is fully implemented
• Consultant - This system has eliminated the
  peaks and troughs of patient flow. I am assured
  of a smooth flow of patients over the course of
  my clinic. It also enables me to include more
  training opportunities for teaching junior staff

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Challenges

• Changing cultural norms behaviour
• Employees
• Punctuality
• Queue discipline
• Feeling of loss of control (By somemost prefer
  new system.)
• Learning to focus on flow, resist urge to fight
  fires
• Patients
• Adherence to appointment times
• Maintaining momentum after initial progress

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Future plans

• Implement mini-kaizen in the workplace staff
  encouraged to come up with ideas that could
  improve job activity, environment and reduce
  waste
• Patient Satisfaction Survey Planned for August
  2009
• Visual controls for patients and staff

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Conclusion

• Industry visit was an eye-opener
• Workplace organisation
• Mistake proofing
• Visual shop
• Handover systems
• 5S
• Continuous flow
• Level loading of work
• The state of the process is obvious, to anyone,
  instantly
• Lean principles and techniques are powerful and
  applicable to healthcare
• Productivity gains
• Staff enrichment
• Patient experience

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Questions?