Digestive Disease Center

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Digestive Disease Center

• Endoscopy Kaizen Event
• 17-February-2005

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Endoscopy Focus Event Team

• Dr. Bob Summers
• Sabi Singh
• Bonnie Wagner, Nurse Mgr
• Cyrill Green, Nurse Asst
• Dr. Doug LaBrecque
• Dr. Jeff Field
• Mary Panther, Nurse
• Mary Pat Mitchell, IT
• Mettie Thomopulos, Administration
• Peg Young, Asst Nurse Mgr
• Tammy Fenchel, Lead Scheduler

Multi-Disciplinary Dedicated Team
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Event Scope and Goals

• Scope Patient Flow Arrival to Departure within
  the Endoscopy Area
• Goals
• Increase thruput of the endoscopy procedures by
  20 with particular emphasis on Colonoscopies
  and/or Upper Endoscopies
• Decrease patient lead time between first call and
  procedure by 30
• Decrease patient length of stay by 30
• Implement at least 5 new protocols around
  constrained resources

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Current State Summary
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Endo/Colon Procedure Volume/Day
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Lead Time to Procedure Routine Requests
Lead Time to Consult and then to Procedure 83
Days
7
Endo/Colon Patient Length of Stay
63
60 50 40 30 20 10 0
Length of Stay Average 204 minutes (3.5
hours) Patient Contact Time 70 minutes (34)
Total Lead Time includes all Patient Wait Time
Sample 67 Endo/Colon Patients (January)
Teams Key Focus Areas To Improve Patient Flow
35
27
24
18
12
6
5
5
2
2
WaitWorkUp
Wait
Wait
Recovery
Consent
Procedure
Check In
Wait/Dress
Connect Pt
To Recovery
To Proc Rm
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Patient Endoscopy Swimlane Diagram
Before
After
After
68 Steps, 23 Delay Points, 6 Decision Points10
Forms, 45 Work-Up Widgets in the Patient Process
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Two Improvement Emphasis

• Patient Flow Improving Patient Satisfaction by
  Reducing Wait Time and overall Length of Stay
• Slot Availability (Capacity) Improving Patient
  and Referring Doctor Satisfaction by expanding
  access and Reducing the Lead Time from Consult to
  Procedure.

Both legs of Improvement are Critical more
efficient flow - leverage the flow with more open
slots.
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No Show Reduction

• YTD Feb 13
• No Show or No Driver or Not Prep or Same
  Day Cancel Rate
• Current 3.2 patients/day
• New Call-Ahead Process - Effective Monday,
  February 20.
• Endoscopic patients will be called 7 days in
  advance by a nurse
• Confirm/remind patient regarding date/time of
  procedure
• Confirm/review with patient prep. meds.
• Re-enforce driver
• Summarize potential points for successful
  procedural appointment

Goal Reduce No Shows by 50 to 1.6
patients/day Complete 32 more procedures/month
Improve Patient EducationEnsure No Surprises for
the Patient or the Staff
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Utilization of Patient Pagers at Check-In

• Before Situation
• Patient can wait in one of 4 different areas
  after check-in
• If delayed, patient may wait in some other remote
  area (library, cafeteria, etc.)
• Patients family could be in any of these
  locations
• After Improvements
• Patient and family provided with pager at
  check-in
• No lost staff time searching for patients or
  family
• Patient and family are processed more quickly
• Patient and family satisfaction is improved due
  to timely feedback of patient status and results

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Nursing Cycle Time-Holding Area
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Workup Process Improvements

• Before Situation
• Information is duplicated
• Electronic workup document has increased patient
  processing time
• Patients are fitted with BP cuff every time BP is
  required
• Nursing staff often required to retrieve IV
  supplies to complete patient prep
• Workup is a bottleneck to patient flow at peak
  volumes
• After Improvements
• Streamlined electronic workup document by
  eliminating 24 screens
• 50-70 reduction in On-Line Assessment
• BP cuffs are applied to patients at workup and
  remain on patient throughout procedure
• IV supplies will be kitted for each patient

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Observed Administrative Time for Doctors
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MD Procedural Administrative Time
Pre-Procedural evaluation and forms (takes 5
minutes)
Time-saving changes

• Review patients medical record HP, All
  MD forms on clip board
• Indications Plans Print out HP in advance
• Greet patient review HP,
• problem to be studied or treated,
  Pre-filled out form elim date
• G-2d Informed Consent (date form x 6)
• Position patient and give sedation NA
  position patient, RN give meds at direction
  of MD
• Fill out B-1c Pre Procedural Assessment IPR form
  with templates widgets Or immediate
  dictation
• w/ on-site transcriptionist
• Do the procedure (takes 10-20 minutes)

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MD Procedural Administrative Time (cont.)
Post-Procedural Forms(takes 7 minutes)
Time-saving changes

• Fill out B-1c Post Proc Assessment IPR form with
  templates widgets Or immediate dictation w
  on-site Transcriptionist
• Sign A-1a Medication Orders No change
• Fill out H-1 Surgical Path Consult Paper or IPR
  form transcribed by NA from MD verbal
  direction
• Dictate proc note after proc Voice
  recognition/digital recorder during
  procedure
• Fill Out A1a Physician Order Form No change
• Fill out Procedural Billing Form Dedicated
  coder/biller fills out from IPR procedure
  note

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Recovery Room Process Improvements

• Before Situation
• Average patient stay in RR is currently 63 min.
• Liver Bx patients stay a minimum of 1 hour
• Inpatients stay a minimum 30 min.
• RR is staffed with 2 nurses
• RR is overloaded in late afternoon
• NA assigned to RR circulates
• After Improvements
• Target patient stay in RR at 45 min.
• Reduce stay for liver Bx to 30 min. if patient is
  stable
• Reduce inpatient stay to 30 min from last
  sedation if they are stable
• RR will be staffed by 1 RN in mornings until
  patient census is 3 or more
• Shift more nursing support to RR in late
  afternoon hours
• Clearly define RR NA duties and streamline to
  allow for backup to Upper Motility. Assign a
  pager

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Liver Biopsy Pre-Procedure Blood Draw
Shorten Length of Stay 1.5 Hours on Blood
DrawsPilot with Liver Biopsies before Expansion
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Two Improvement Emphasis

• Patient Flow Improving Patient Satisfaction by
  Reducing Wait Time and overall Length of Stay
• Slot Availability (Capacity) Improving Patient
  Satisfaction by expanding access and Reducing the
  Lead Time from Consult to Procedure.

Both legs of Improvement are Critical more
efficient flow - leverage the flow with more open
slots.
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Current Endo/Colon Procedure Hours
Excludes Time AwayVacation and VA
44.5 Hours Max/week available for Endo/Colons
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Capacity Slot Ideas Endo/Colon

• Increase afternoon blocks from 3 hours to 3.5
  hours Impact 2.5 Hours/week
• Move 2 afternoon Wed blocks to morning.Impact 3
  Hours/week
• Work thru Grand Rounds if doing Thursday
  afternoon Procedures. Impact 1 Hour/week
• Shift 4 hours of Dr. Summers Clinic to
  Procedures and shift Dr. Fields Friday morning
  teaching (1hour)

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Proposed Endo/Colon Procedure Hours
Excludes Time Away PTO/VA
Increase from 44.5 to 56 Hours Max/week for
Endo/Colons
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Other Capacity Improvements

• Schedule 2 Endo/Colon out-patient procedures for
  In-Patient Consult Physician on Tuesday,
  Wednesday, and Thursday (Opens 6 slots/week)
• Schedule Endoscopies in open Liver Biopsy Slots.
  (12 open slots/month based on January)

Potential for an additional 36 slots/month
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Typical Suite Operating Model
Typical Model 1 Physician 1 Nurse 1 NA 1
Room 30 min/physician/patient

• Issue Model isnt Flexible
• Late Patient or No-Show forces staff to be idle
• Physician may wait on Room Turn-Around and/or
  Staff to re-assemble
• If procedure goes quickly, staff is idle

Slot Patients 100 1 130 1 200
1 230 1 300 1 330 1 400 1
Look for Opportunities to break the Paradigm
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Open Access Operating Model
Goal Create an efficient operating approach
specifically for Screening Colonoscopy Patients.

• Screening Colonoscopy Patients
• Significant growing service - Currently have a
  backlog of patients
• Clinic visit not required in advance of
  procedure
• Typically healthy patients with predictable
  procedure length
• Patients do not need to see a particular
  Physician

• 20-35 Better Doc Utilization
• No-show or late patients dont result in
  downtime by the staff move on to the next
  patient
• Extra room allows for NAs to create pull by
  having next patient in room ready for first
  available doctor.

Slot Patients 100 4 130 3 200
2 230 3 300 3 330 2 400 1
Open Access Model 2 Physicians 2 Nurses 3 NAs 4
Rooms 23 min/physician/patient
Pilot on March 3rd 1-430pm with Field
SummersExpectation is to establish a Weekly Open
Access Block
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Focus Event Impact - CDD
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Key Next Steps

• Communicate this same information with rest of
  Staff and Physicians
• Begin a weekly review of status on Homework
  action items
• Begin Tracking Impact on a quarterly basis