BAR Launch: Gate Check 1

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Lean and Pre-Admission Testing (PAT) Cost
Center to Profit Center Presentation Vinnie
Brigandi, Director Process Improvement , Solaris
Health System Thomas Decker, GE
Healthcare 03.17.09
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Presentation Agenda

• GE Healthcare
• Solaris Health System Overview
• Case Study
• Sustaining Change
• Lessons Learned
• QA

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GE Healthcare
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GEs Change Research

• 100 of all changes evaluated as successful had
  a good technical solution or approach
• Over 98 of all changes evaluated as
  unsuccessful also had a good technical solution
  or approach

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Leadership Practices
Effective Results (E) are equal to the Quality
(Q) of the solution times the Acceptance (A) of
the idea, Accountability (A) of the
implementation and Alignment (A) to the
organizations strategic goals. Q x A
E
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A proven formula for results
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Benefits of Lean
Higher customer satisfaction
Any process or value stream
Lead Time / Cycle Time

• Reduced cycles
• Better delivery
• More capacity
• Better quality
• Productivity

Before
Work . . .
Value Add Time
After
Wait / Waste . . .
Non Value Add Time
Lean attacks waste here
Increased process velocity, reduced waste,
improved customer experience
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The underlying principles

• Create standards for all key processes
• Follow standard first, then continuously improve

Standardize
Cannot recognize defects if standards are not
defined
Solve
Customer Focus
Stop
Prevent abnormalities from becoming the
standard
Make problems visible

• Go see
• Ask why 5 times
• Demand root cause action

• Dont accept, make or pass defects
• Stop and surface the problem

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How to do LEAN the Process Journey
Go back after 9 months to start Journey again.
Identify/Prioritize Project Funnel
Cross functional Speedily implement Recommended
changes
Visualize entire Process end to end. Begin
with existing Process map
Value Stream map end to end process CURRENT
STATE
create FUTURE STATE Value Stream map (A vision
at this stage)
Assumes process stable (limited variation in
workflow)
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The Perioperative Value Stream Roadmap

Impact
Difficulty
Activity
Event
OR - Room Turnover Efficiency
Increase the number of trays ready for first case
H
M
Kaizen
Decrease the number of defects in missing or
wrong instruments
Decrease the requirements for flash sterilizing
Improve the timely delivery of trays
Improve the accuracy of tray contents and return
underutilized instruments to
H
L
Work-Out
general inventory
OR Input - Front End
H
L
Kaizen
Reduce overall turnaround time and increase
throughput through the PAT
Decrease the defects passed on to SDS (incomplete
paperwork)
Decrease the cycle time for medical clearance
Kaizen
In 2007, Solaris performed an OR
Value Stream Mapping session.
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Solaris Health System Overview
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Solaris Health System

• JFK Medical Center
• JFK Medical Center-Muhlenberg Campus
• JFK Johnson Rehabilitation Institute
• 3 Long Term Care Facilities

• Diabetes Center of New Jersey
• Mediplex Surgery Center
• New Jersey Neuroscience Institute
• Whispering Knoll, Assisted Living

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Performance Excellence
Solaris 2008 Key Strategic Initiatives
Emergency Services
Patient Flow
Perioperative Services
Accelerate and Sustain Improvements
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Case Study Pre-Admission Testing (PAT)
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Kaizen Scope/Objectives

• Scope
• From the time the patient is identified as
  requiring a Pre-Admission Testing (PAT) visit to
  the time the patients PAT visit is complete and
  the patient and chart is considered ready for
  Same Day Surgery (SDS).
• Objectives
• Reduce MD order defect rate by 40.
• Develop a standardized and efficient process with
  less waste.
• Increase revenue by unblocking the schedule.

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PAT Value Stream Map
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Key Findings

• Charts missing MD orders, HPs, medical
  clearances, etc.
• Ancillary services not notified until patient
  ready for test.
• One FTE Nurse focused on hunting and gathering
  documentation thereby precluding the FTE from
  direct patient care. This process artificially
  blocked the PAT schedule.
• Multiple checks for initial test results and
  sorting of documents.

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PRIORITIZATION MATRIX
Prioritized key Kaizen action items (based on the
value stream map) by impact and difficulty to
optimize success.
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Standardization

• MD order sent at time of PAT scheduling.
• Anesthesia rounds to review abnormal test
  results, two times per day.
• Streamlined standardized chart review process
• Rolling carts
• Visual Management
• Escalation process for charts missing key
  documents

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Recognizing and Managing Change

• Change Chart
• Identified the the MD Offices that would be
  receptive to the new process.
• The MD innovators were identified to influence
  the remaining 80 of the physician population to
  create momentum and overcome the inertia of the
  resistors. 

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PAT Communication Plan

• A communication plan, based on the change chart,
  was used to monitor progress along both the
  technical (Q) and cultural dimensions (A).
• The plan framed the why, the what, and the
  who critical to making the change.

Mobilizing the commitment of key stakeholders was
essential to the success of the change.
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Sustaining Change Process Control Board
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PAT Process Control Board

• PAT Orders
• Track the number of charts without MD orders
• Completed Charts
• Derive the percentage of defects
• Segment defect reasons, i.e. HP, Medical
  Clearance, etc

Daily tracking provided management with
actionable data to reinforce process requirements
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Making Change Last
Kaizen Objectives
Results

• Reduce MD order defect rate by 40.
• Develop a standardized and efficient process
  with less waste.
• Increase revenue by unblocking the PAT schedule.

Post-Kaizen
Pre-Kaizen
MD Order Defects
80
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Process Cycle Efficiency
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72
37-40 per day
Volume
17-18 per day
(A)
Charges
3.5 M
4.6 M
Charges reflect 2007 and 2008 YTD respectively
Annualized increase of 320K in payments over 2007
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Lessons Learned

• Engage early and often surgeons,
  anesthesiologists and referring MD offices.
• Results from Kaizen provided early wins and the
  foundation for subsequent Kaizens.
• Leadership Practices (Q x A E)
• The front-line staff accept and implement the
  Kaizen initiatives while the Executive Team
  drives the Lean philosophy through accountability
  and strategic alignment.

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Q A
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Thank You Questions? Ideas? Comments? Please
contact Vinnie Brigandi vbrigandi_at_solarishs.org
Thomas Decker thomas.decker_at_ge.com