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Improving patient satisfaction scores, such as CAHPS, is key for driving practice reputation and reimbursements.
Healthcare organizations with high patient satisfaction and CAHPS scores see a multitude of benefits. High patient satisfaction scores usually result in higher reimbursement payments from CMS, better patient retention rates, and the assurance for hospital staff that they fostered a positive experience for patients.
A May 2016 report from Vocera showed that patient satisfaction is the top-ranked priority at healthcare organizations. Due to the importance of ensuring favorable feedback from patients, the demand for patient experience officers and patient advocate executives is increasing, with these professionals pulling equal rank with other C-suite executives, the report said.
The primary measure for patient satisfaction is the Consumer Assessment of Healthcare Providers and Systems (CAHPS). The CAHPS survey is developed and funded by the Agency for Healthcare Research and Quality (AHRQ) in partnership with CMS, and forms a component of some value-based reimbursement programs.
CMS also uses CAHPS scores to inform its star ratings, which are publicly available ratings about the quality of healthcare facilities.
Several types of CAHPS surveys are utilized throughout the care continuum, ranging from hospitals to nursing homes to health plans. However, the Hospital CAHPS (HCAHPS) and Clinician and Group CAHPS (CGCAHPS) are the most prominent and commonly used surveys.
Both surveys measure many of the same factors, including nurse care, doctor care, and facility environment.
The HCAHPS survey also includes questions about experiences within the hospital, including pain management, and continuity of care experiences.
CGCAHPS surveys target their questions to the general practitioner, asking questions about ease of healthcare access and how often the patient has been visiting the office.
Because HCAHPS and CGCAHPS are used for both reimbursement and patient rating purposes, it is important for healthcare organizations to improve their scores. Healthcare organizations can improve their CAHPS scores by understanding what is important to patients, what the surveys measure, and how to meet patient needs.
Improving Patient-Provider Communication
The first two sets of HCAHPS questions pertain to nurse and physician communications with patients. These questions ask whether nurses and physicians communicated clearly with patients, and whether patients understood their diagnoses, prognoses, and treatment options.
Clear communication about healthcare information is integral to a positive healthcare experience, experts say. Hospitalization is often a stressful and worrying time for patients, and made even worse when clinicians do not adequately communicate what is going on and how they will treat a patient’s ailments.
In addition to allaying patient worry, providing meaningful explanations of conditions and treatments will help the patient taken ownership of her own health.
“Patients have a need for information,” explained Deirdre Mylod, PhD, Executive Director of the Institute for Innovation and Senior Vice President of Research and Analytics at Press Ganey.
“It’s not just making consumers happy to meet that need, but it’s also providing the right care. When you give people the right information, they can engage in care, they can be active participants, they’re better prepared to care for themselves at home, they’re less likely to be readmitted.”
Clear communication will require collaboration between the different members of the care team, added Mylod.
“As a patient, when one team member tells me one thing and somebody else tells me another, now I’m afraid and I’m thinking you’re not working together. Now I’m more scared than I need to be in a hospital,” she pointed out.
HCAHPS also asks patients whether nurses and physicians treated them with respect and empathy. Clinicians must tap into their interpersonal skills to provide compassionate care to their patients, while being mindful of cultural norms and barriers.
The healthcare industry might be falling short in this respect. A January 2017 survey conducted by Oliver Wyman and the Altarum Institute found that 40 percent of low-income patients have walked away from appointments feeling disrespected.
The survey, funded by the Robert Wood Johnson Foundation, showed that in addition to reducing patient satisfaction, lacking compassion also lowered quality of care. Patients who felt disrespected were three times less likely to trust their clinicians, and two times less likely to adhere to treatments.
Healthcare organizations should support their clinicians in pursuit of being more empathic. Organizations can host cultural sensitivity seminars, work with patients to continue to develop their interpersonal skills, and educate clinicians on evidence-based best practices for enhancing patient-provider communication.
Improving the Physical Hospital Environment
Two HCAHPS questions pertain to the hospital environment: hospital cleanliness and hospital noise levels.
In order to maintain an appropriately clean and sanitary facility, organizations must support their custodial staff and reinforce the importance of a healthcare facility being clean.
The American Hospital Association has long advocated for improving the hospital setting for patient satisfaction. In a 2016 guide, AHA listed the ways in which organizations can create environments more suitable for patient rest and recovery.
To create a quiet and peaceful environment, AHA says hospitals should implement and enforce rules about quiet hours and lights-out times.
“It makes sense that patients rate hospitals poorly when they cannot get good sleep or rest and have the additional stress of noise added to the already stressful situation of being unwell,” AHA wrote. “Data shows that noise in hospitals is the factor that scores lowest on HCAHPS scores nationwide.”
Healthcare organizations can take it a step further than HCAHPS mandates. Many hospitals are turning to their patients to inform room design that will facilitate a more comfortable experience.
When designing its new facilities in Delaware and Orlando, leaders at Nemours Children’s Health consulted with its patient and family advisory board to decide which features would best suit pediatric patient rooms.
“The parents came in and tested all of the furniture that they might be sleeping on in the rooms. They provided input into what we actually purchased,” recalled Nemours Chief Information Officer Bernie Rice.
“The children came in as well and helped pick colors and room layouts as far as if the counter was too high,” he continued. “They were very valuable and heavily influenced our construction and design to make sure it was a very family- and patient-friendly environment.”
Being Attentive and Reducing Unnecessary Discomfort
One highly-debated part of patient experience surveys is pain management. Amidst a raging opioid abuse epidemic, many experts question whether pain management should be a part of patient satisfaction scores that result in provider reimbursements. By tying payments to pain management, some clinicians may feel compelled to prescribe opioids when there could be other potentially less-risky forms of pain management.
In November 2016, CMS removed the pain management questions from the HCAHPS survey. However, the agency maintained that pain management is an important part of patient care and experience.
“CMS continues to believe that pain control is an appropriate part of routine patient care that hospitals should manage, and is an important concern for patients, their families, and their caregivers,” CMS said in a public statement. “CMS is continuing the development and field testing of alternative questions related to provider communications and pain, and will solicit comment on these alternatives in future rulemaking.”
While the pain management portions of the HCAHPS survey are currently under construction, clinicians should still work to reduce unnecessary patient discomfort.
Press Ganey is adopting this approach when consulting on patient experience, Mylod said.
“The way that we approach improvement for patient experience measures is to reframe it,” she explained. “The exercise is not to make consumers happy. The exercise is to reduce patient suffering.”
To boost scores in this realm, Mylod suggests clinicians – especially nurses – become even more attentive. This means not only answering call buttons, but also making regular rounds to hospital beds to ensure they meet all patient needs.
During these rounds, nurses can ask if the patient needs assistance using the restroom or if they need an object, such as a television remote, handed to them. Paying attention to these seemingly inconsequential needs could reduce adverse safety events, Mylod explained. If a patient gets up to retrieve a book, for example, he could fall and hurt himself, affecting the patient experience, increasing length of stay, or requiring additional expenses related to an injury.
Streamlining the Discharge and Follow-up Process
HCAHPS asks patients about how doctors and nurses managed continuous care and the discharge process. The survey asks whether clinicians checked in on post-discharge care plans, made it clear which provider will follow-up with ongoing needs, and whether that care will be adequate for the patient’s condition.
At patient advocacy group Planetree, leaders have developed a hospital discharge plan to ensure clinicians meet patient needs.
The plan includes identifying a family care partner that will help take care of the patient following hospital discharge, said Planetree’s Director of Research Jill Harrison, PhD.
From there, clinicians check in with the patient and appointed caregiver to determine which functions they will need to learn for optimal at-home care.
“Planetree has a program that allows people to say that they want help with wound changes, or help ambulate their loved one, or help check a tracheotomy if the patient has one,” Harrison said. “Caregivers go through a training program with the nursing staff and learn how to provide that care so that when patients get out of the hospital setting their family members are ready to take that all on.”
Other key healthcare players are advocating for a similar strategy. AARP has been sponsoring a law in state legislatures across the country to support family caregiver engagement. The organization says caregiver engagement will help support continuity of care.
Research confirms that family caregiver engagement can reduce hospital readmissions by up to 25 percent.
Hospitals that implement family caregiver engagement and discharge plans may see not only increases in HCAHPS scores, but in quality of healthcare, as well.
The importance of improving patient satisfaction and CAHPS scores is well-founded. These scores help inform CMS value-based reimbursements and hospital ratings published on the CMS website. Many healthcare organizations also use these scores to inform their own internal practice improvement processes.
However, when it comes to improving patient satisfaction, it is also important for practice leaders to look beyond the survey. Improving patient satisfaction means understanding the facility’s unique patient population and its needs. What will please one group of patients may not satisfy another, and hospital leaders must bear that in mind.
While supporting initiatives specifically geared toward improving CAHPS scores, healthcare organizations should also consider projects that will serve their unique population.
Issuing practice-specific patient input surveys or consulting with a patient advisory council will help healthcare organizations move beyond surface-level satisfaction and find solutions that will be truly meaningful for patients.
Serious about Patient Safety: Akron Children’s Hospital Uses Lean Six Sigma and Minitab in the NICU
The hospital encourages employees across all skill levels and departments to become involved in quality improvement, offering several levels of Lean Six Sigma training. As part of its green belt training and certification, employees learn to use Lean Six Sigma by leading and completing long-term projects with the guidance of experienced black belts.
One such green belt project, which began at the hospital’s Mahoning Valley, Ohio campus, had a goal to decrease one particular safety event—unplanned extubations in the hospital’s neonatal intensive care unit (NICU). To complete this project, the hospital improvement team relied on Lean Six Sigma tactics and the data analysis tools in Minitab Statistical Software.
An intubation is a medical procedure in which a breathing tube is placed into a patient’s trachea. This tube connects the patient to a machine called a ventilator, which helps the patient breathe. The procedure is common for both pediatric patients and adults in intensive care, but is most common for premature newborn babies residing in a hospital’s NICU. Babies born prematurely often have undeveloped lungs, which cause breathing problems and the need for the assistance of a ventilator.
Although this medical procedure is commonly performed, it is not without risk, and can cause trauma to or introduce an infection into the patient’s airway. Unplanned removal of the breathing tube, which is also known as an unplanned extubation, is a likely occurrence that can cause harm. Unplanned extubations are the fourth most common adverse event in NICUs across the U.S.
Akron Children’s Hospital’s Department of Respiratory Care had been collecting data on the rate of unplanned extubations in the Mahoning Valley NICU for well over a year, but had not had the capacity to investigate the occurrences further. Bonnie Powell, a Registered Respiratory Therapist and manager of respiratory services at Akron Children’s Hospital, was a green belt candidate during the time unplanned extubation data were collected. As part of her Lean Six Sigma training and certification, she set out to lead a project that would decrease the rate of unplanned extubations in the Mahoning Valley NICU.
“I knew this project was the perfect fit for me because as a respiratory therapist, I’ve been part of the frontline staff primarily responsible for intubating,” Powell says. “When you’re the one actually putting the tube into the patient, it just affects you more because you know the trauma that you could be causing to them.”
How Minitab Helped
While there’s not a true benchmark rate that NICUs should strive to stay below regarding unplanned extubations, the Vermont Oxford Network—a research collaboration of nearly 1,000 global NICUs including Akron Children’s—considers 2 in 100 intubated patient days to be the upper limit of acceptable. Previous data collected on the rate of unplanned extubations at the Mahoning Valley NICU revealed a rate of 3 in 100 intubated days.
“Any unplanned extubation has the potential to cause harm to the patient and negatively impact overall patient satisfaction,” says Powell. “We wanted to improve our performance on this metric.”
Powell’s Lean Six Sigma project team included a multidisciplinary group of nurses, respiratory therapists, a neonatal nurse practitioner, and a neonatologist.
The team began by using Lean Six Sigma tools to brainstorm reasons why unplanned extubations were occurring, as well as solutions for stopping them. “The fishbone diagram and cause maps were among the most helpful tools we used,” Powell says. “We looked at the highest impact solutions, as well as how easy they would be to implement, and prioritized solutions from there.
“This step helped us to organize and roll out our seven improvements into two phases,” she says.
Along with more frequent communication between nurses and respiratory therapists before, during, and after an intubation, as well as educational information distributed in meetings and via email, one improvement implemented was the “two to turn” rule. “Anytime an intubated patient is repositioned, one caregiver is turning the patient and another is holding the tube at the patient’s mouth,” Powell explains.
The team applied the improvements for several months, as collecting enough data to meet the required 100 intubated days for pre- and post-improvement comparison proved difficult for many reasons.
“There is a continuing trend in neonatal care to use devices such as masks and nasal prongs to connect the patient to the ventilator to help with breathing. When these devices are used, there is no need for a breathing tube, which reduces the number of intubated days and lengthened our post-improvement data collection period,” Powell says. “That, coupled with greater attention to our weaning protocol, which focused on shortening the time babies need ventilator support of their breathing, contributed to why we saw a reduced amount of intubated days.
“Of course, fewer intubated days was a good thing in this case, and supported the idea that our improvements were working,” adds Powell.
To compare unplanned extubations, pre- and post-improvement, the team visualized their data using control charts in Minitab Statistical Software.
To verify their results statistically, the team ran a 2 proportions test in Minitab to see if their unplanned extubation rates decreased after improvements were put into place.
The analysis showed the team that after improvements were implemented, the unplanned extubation rate had indeed decreased.
The team also used Minitab to perform process capability analysis both pre- and post-improvement. This tool provided another before-and-after comparison of unplanned extubation rates, and aided the project team in assessing whether the new process was capable and in statistical control.
“I have never taken a statistics course and have no background in this type of work,” Powell notes, “but Minitab, coupled with the instruction I received from the Center for Operations Excellence, made it easy for me to analyze and understand my data.”
Trauda Gilbert, deployment leader for the Center for Operations Excellence at Akron Children’s, echoes Powell. “To be able to use Minitab to visually demonstrate the before and after effect with a control chart, which you can then share with your team and champion is really valuable. Minitab also makes it easy for front-line staff to document that they have made a statistically significant difference. To be able to do that without having to interact with a biostatistician or one of the other very rarely found statistical resources in our organization, is very beneficial,” she notes.
“Healthcare quality is a little different than manufacturing because we can’t just run a DOE and tweak a process line,” says Gilbert. “Even though we’re different, Minitab still helps us out.”
The data revealed a dramatic reduction in intubated days after the improvements were made, as well as a considerable reduction in the rate of unplanned extubations at the Mahoning Valley campus. The reductions brought their rates in line with the Vermont Oxford Network’s suggestion of 2 unplanned extubations in 100 intubated patient days.
“This project showed us that simple improvements can create real change,” says Powell. “The cultural change this project instilled in our team was exciting—the recognition that even they could make a difference is huge.”
Cost savings resulting from the reduction in supplies and staff time needed to care for unplanned extubations can be calculated, but the overall financial impacts are hard to quantify. “The larger costs of unplanned extubations—such as a longer NICU length of stay, ventilator-associated pneumonia, and other setbacks that the patient can experience from the event—can be difficult to tease out,” Powell says.
“Neonatal patients are some of our key customers here,” she continues. “Due to the fact that they were born early, they come back to our institution for care frequently, especially initially. Making sure they have a safe experience early is critical, because the results of good care at this stage can have exponential benefits for patients in the future.”
In addition to improving the patient experience, the project helped Powell obtain her Lean Six Sigma belt certification. “I did get my green belt as a result, and we’ve also rolled out selected improvements to the NICU at our Akron campus,” she says. “We’re in the process of collecting data there as well, so this project didn’t just stop in Mahoning Valley.”
Powell’s project is just one example of an estimated 300 documented projects that have been completed throughout the Akron Children’s organization. The total financial savings of the hospital’s operations excellence program is estimated to be more than $25 million since its official beginnings in 2008.
Learn more about lean six sigma in healthcare : Six Sigma Master Class – Improving Healthcare Processes
Since 2001, Thibodaux Regional Medical Center (TRMC) in Louisiana has applied Six Sigma and change management methods to a range of clinical and operational issues. One project that clearly aligned with the hospital’s strategic plan was an initiative to reduce nosocomial or hospital-acquired pressure ulcers, because this is one of the key performance metrics indicating quality of care.
Although the pressure ulcer rate at the medical center was much better than the industry average, the continuous quality improvement data detected an increase between the last quarter of 2003 and the second quarter of 2004.
In October 2004, a Six Sigma project to address this issue was approved by the hospital’s senior executives. A team began to clarify the problem statement. Their vision was to be the “Skin Savers” by resolving issues leading to the development of nosocomial pressure ulcers. The project team included a Black Belt, enterostomal therapy registered nurse (ETRN), medical surgical RN, ICU RN, rehab RN and RN educator.
Scoping the Project
Through the scoping process, the team determined that inpatients with a length of stay longer than 72 hours would be included, while pediatric patients would be excluded. The project Y was defined as the nosocomial rate of Stage 2, 3 and 4 pressure ulcers calculated per 1,000 patient days. Targets were established to eliminate nosocomial Stage 3 and Stage 4 pressure ulcers and reduce Stage 2 pressure ulcers from 4.0 to less than 1.6 skin breaks per 1,000 patient days by the end of the second quarter of 2005.
The team developed a threats and opportunities matrix to help validate the need for change (Table 1). They encountered some initial resistance from staff, but were able to build acceptance as the project began to unfold.
|Table 1: Threats and Opportunities Matrix|
|Short Term||Increase length of stay||Improve quality of care|
|Increase costs||Decrease medical complications to patient|
|Increase medical complications to patient|
|Long Term||Decrease patient satisfaction||Improve preventative care measures|
|Increase morbidity rate||Improve hospital status/image|
|Decrease physician satisfaction||Increase profitability|
|Increase number of lawsuits||Improve customer satisfaction|
|Loss of accreditation|
Measurement and Analysis
During the Measure phase, the team detailed the current process, including inputs and outputs. Using cause and effect tools, process steps having the greatest impact on the customer were identified as opportunities for improvement. The team also reviewed historical data and determined that overall process capability was acceptable, but that the sub-processes had a great deal of room for improvement. Improving these sub-processes would positively affect the overall process and further improve quality of care.
Measurement system analysis on the interpretation of the Braden Scale was performed to verify that results obtained by staff RNs were consistent with the results obtained by the enterostomal therapy RN, because this is the tool used to identify patients at risk of developing a pressure ulcer. This analysis indicated that the current process of individual interpretation was unreliable and would need to be standardized and re-evaluated during the course of the project.
A cause and effect matrix was constructed to rate the outputs of the process based on customer priorities and to rate the effect of the inputs on each output (Figure 1). The matrix identified areas in the process that have the most effect on the overall outcome, and consequently the areas that need to be focused on for improvement (Table 2).
The team identified several critical Xs affecting the process:
- Frequency of the Braden Scale – The Braden Scale is an assessment tool used to identify patients at risk of developing pressure ulcers. Policy dictates how frequently this assessment is performed.
- Heel protectors in use – Heel protectors are one of the basic preventative treatment measures taken to prevent pressure ulcers.
- Incontinence protocol followed – Protocol must be followed to prevent against constant moisture on the patient’s skin that can lead to a pressure ulcer.
- Proper bed – Special beds to relieve pressure on various parts of the body are used for high-risk patients as a preventative measure.
- Q2H (every two hours) turning – Rotating the patient’s body position every two hours is done to prevent development of pressure ulcers.
|Table 2: Data Analysis|
Braden Scale Frequency
Data analysis revealed that the bed type was not a critical factor in the process, but the use of heel protectors, incontinence protocol compliance, and Q2H turning were critical to the process of preventing nosocomial pressure ulcers. The impact of the Braden Scale frequency of performance was not identified until further analysis was performed (Figure 2).
Evaluating data specific to at-risk patients, the team separated populations who developed nosocomial pressure ulcers from those who did not have skin breakdowns. The Braden Scale result at the time of inpatient admission from each population was analyzed to see the effect on development of a nosocomial pressure ulcer. One unexpected finding was that the admit Braden Scale result was higher for patients who develop nosocomial pressure ulcers than for those who do not develop them, showing that patients at risk are not being identified in a timely manner, thus delaying the initiation of necessary preventative measures.
The team then looked at defects for Braden Scale frequency of performance for each population of patients using a chi square test. They found the frequency of Braden Scale performance did have an effect on the development of nosocomial pressure ulcers. This was confirmed with binary logistic regression analysis (Table 3).
|Table 3: Binary Logistic Regression Analysis|
Braden Scale Defects
Q2 Turn Defects
The most significant X is the Braden Scale frequency of performance. This analysis confirmed the need to increase the frequency of Braden Scale performance to identify at-risk patients.
Recommendations for Improvement
During the Improve phase, recommended changes were identified for each cause of failure on the FMEA with a risk priority number of greater than 200. Some of the recommendations include:
- Frequency of Braden Scale performance to be increased to every five days
- Braden Scale assessment in hospital information system (HIS) to include descriptions for each response
- Global competency test on interpretation of Braden Scale to be repeated annually
- Prompts to be added in HIS to initiate prevention/treatment protocols
- ET Accountability Tracking Tool to be issued for non-compliance with prevention and treatment protocols as needed
The Braden Scale R&R was repeated after improvements were made on the interpretation of results. The data revealed an exact match between RNs and the ETRN 40 percent of the time, and RNs were within the acceptable limits (+/– 2) 80 percent of the time. Standard deviation was 1.9, placing the results within the specification limits. The data indicated that the RNs tend to interpret results slightly lower than the ETRN, which is a better side to err on because lower Braden Scale results identify patients at risk of developing pressure ulcers.
The Control Phase
Another round of data collection began during the Control phase to demonstrate the impact of the improvements that had been implemented. A formal control plan was developed to ensure that improvements would be sustained over time, and the project was turned over to the process owner with follow-up issues documented in the Project Transition Action Plan.
The team implemented multiple improvements, including compilation of a document concerning expectations for skin assessment with input from nursing and staff. They also gave a global competency test on interpretation of the Braden Scale, which will be repeated annually. The Braden Scale frequency was increased to five days, and they corrected the HIS calculation to trigger clinical alerts for repeat of the Braden Scale. Prompts were added for initiating the Braden Scale, and monthly chart audits were developed for documentation of Q2H turning. A turning schedule was posted in patient rooms to identify need and document results of Q2H turning of patient. Additional solutions included the following:
- ETRN to attend RN orientation to discuss skin issues
- Revise treatment protocol to be more detailed
- Wound care products to be reorganized on units
- Unit educators to address skin issues during annual competency testing
- CNA and RN to report at shift change to identify patients with skin issues
- Task list to be created for CNAs
- ET accountability tracking tool to be issued for non-compliance with prevention and treatment protocols as needed
Results and Recognition
Since this was a quality-focused project, the benefits are measured in cost avoidance and an overall improved quality of care. A 60 percent reduction in the overall nosocomial pressure ulcer rate resulted in an annual cost avoidance of approximately $300,000.
To make sure their initiatives are producing a positive impact on the patient care environment, the hospital continuously measures patient and employee satisfaction through Press Ganey. Inpatient satisfaction is consistently ranked in the 99th percentile and employee satisfaction in the 97th percentile. TRMC also has received recognition in the industry for their achievements, including the Louisiana Performance Excellence Award for Quality Leadership (Baldrige criteria), Studer Firestarter Award and Press Ganey Excellence Award.
“This project is a perfect example of the need to verify underlying causes using valid data, rather than trusting your instincts alone,” said Sheri Eschete, Black Belt and leader of the pressure ulcer project at TRMC. “Six Sigma provided us with the tools to get to the real problem so that we could make the right improvements. There had been a perception that not turning the patients often enough was the issue, but the data revealed that it was really the frequency of the Braden Scale. Leveraging the data helped us to convince others and implement appropriate changes.”
The nosocomial pressure ulcer rate is monitored monthly as one of the patient-focused outcome indicators of quality care. The results are maintained on the performance improvement dashboard (Figures 3 and 4).
Learn more about lean six sigma in healthcare : Six Sigma Master Class – Improving Healthcare Processes
By Tonya Vinas
Akron Children’s Hospital (ACH), a regional pediatric care system headquartered in Northeast Ohio, could be compared with David, the young lad who courageously brings down a giant in a classic Old Testament tale.
In this story, though, David battles two giants.
Akron is about 35 miles south of Cleveland, where two nationally ranked pediatric hospitals draw families from around the world who need specialized care for their children’s complex medical problems. Parents are attracted to the hospitals’ international reputations for being among the best: The Cleveland Clinic’s Children’s Hospital and University Hospital’s Rainbow Babies and Children’s Hospital are known for breakthrough research, life-saving surgeries and treatments, and other medical innovations. They also aggressively recruit gifted doctors, leading scientists, and other medical experts at the top of their professions.
But ACH, which certainly has a stellar regional reputation, is taking a unique weapon into the field as it battles for a bigger slice of the state’s pediatric care market. While the two Cleveland hospitals have continuous-improvement programs, neither has made continuous improvement a strategic imperative across its entire enterprise as ACH has.
The hospital’s Center for Operations Excellence (COE) is the engine that propels all employees and functions toward the growth goals set by executives and board members in hoshin kanri (strategy deployment) planning. Leaders are confident that the COE and its lean six sigma-focused training and project leadership give ACH enough competitive advantage to succeed, even in the same geographic market as two healthcare giants.
ACH’s expansion plan includes increasing the number of patients served both geographically and within certain sub-specialties; becoming the No. 1 choice for parents and referring physicians through quality achievements and availability of services; improving on infrastructure, quality, and clinical programs; and becoming the primary site for pediatric medical research in Northeast Ohio.
Already, the three-year-old COE has been widely embraced and highly effective. Projects have saved ACH millions of dollars, increased utilization of expensive assets, and reduced wait times and processing for patients and their families. The short-term gains are important, said Doug Dulin, the COE’s senior director, but the learning and commitment that each project builds internally are more crucial.
“What it comes down to is that we have to create a competitive advantage,” said Dulin, who learned the Toyota Production System at Aoyama Seisakusho, a Tier One supplier to Toyota Motor Manufacturing. “So how can we transfer what we’ve already done into every segment of the hospital? That’s how the Center for Operations Excellence fits in. This is a long-term journey.”
Akron Children’s Hospital at a Glance
- Largest pediatric healthcare system in northeast Ohio.
- Operating two freestanding pediatric hospitals and offering services at nearly 80 locations.
- Pediatric specialties draw half a million patients annually, including children, teens, and adults from all 50 states and around the world.
Level-Loading Schedule Improves Quality, Access, and Revenues
In addition to the challenge of having two highly regarded competitors in the market, ACH must do much more with much less. It doesn’t receive the numerous large grants and donations that the others do; and since all of the hospital’s patients are children, it can’t rely on Medicare reimbursements. Also, both the Clinic and UH are closely aligned with Case Western University Medical School in Cleveland, and so have access to more intellectual property, research programs, emerging technologies, and other assets than ACH has.
The hospital system’s smaller and less complex operation, however, seems to have been an advantage for quickly absorbing the lean culture. Evidence of how open all levels of the organization have been to lean is the speed with which a large number of employees — including doctors — have come together to identify problems, find the root causes, and then agree on countermeasures.
“There’s something about the culture at Children’s that allowed this to be very effective, very quickly,” said Board Member Bill Hopkins. “They were just primed for this. It speaks volumes about the commitment from everybody — the leadership, staff doctors, nurses.”
For example, MRI scheduling was one of the first areas the COE addressed because it had potential for significant and fast improvement, and because the hospital had not been able to effectively utilize a second MRI machine it had purchased. The most apparent barrier was a bottleneck in scheduling.
A kaizen event revealed that variability was the root cause:Children are more prone to move during exams when they need to be still, a reality that extends their appointment times because readings frequently need to be delayed or redone. On any given day, more than half of the hospital’s patients are five-years-old or younger, and so are particularly prone to moving during exams. Some children need to be sedated to keep them still. This causes more variability because a doctor needs to administer the sedation, and doctors’ schedules routinely change without notice because of emergencies and other unexpected events. The result was a backlog of patients with appointments, and long wait times for those needing new appointments.
The two-day kaizen — which included radiologists, radiology technologists, schedulers, nurses, and the employees who handle insurance authorization and registration — produced multiple solutions:
- Modifying the master schedule.
- Streamlining the insurance authorization Process.
- Implementing standardized work instructions.
As is often the case with a level-loading solution, modifying the master schedule seemed counterintuitive, but it worked. More time was scheduled for each exam, a change that made it easier for the end-to-end Process to absorb variability and remain level (on schedule). This eliminated the bottlenecks that were causing the long wait times for exams and results. In cycle-time terms, the “appointment-to-results” cycle shrunk drastically as the department got its scheduling Process under control. As a result, more capacity opened, and this allowed an increase in throughput (appointments) without adding resources.
“Before the kaizen, the hospital was doing about 86 MRIs per week. Now, on average, we are doing 112,” Dulin said. “That is good news for our patients and the physicians who are waiting on the results of those tests. Instead of waiting 25 days for an uncomplicated exam, families can now schedule same-day appointments.” (See chart: Outpatient MRI Appointment Wait Times.)
The project significantly improved the hospital’s bottom line, with $1.2 million in additional revenue attributed to the better MRI scheduling.
It also earned ACH an honorary mention award at the International Quality and Productivity Center’s Lean six sigma & Process Improvement Summit in January, 2011. The award was in the category of “Best Process Improvement Project Under 90 Days,” with Akron Children’s competing against five other international companies and organizations that were selected as finalists.
Surgery: Greater Capacity, Higher Quality without $3.5 Million Expansion
Perhaps the most striking example of how lean processes will feed ACH’s efficient growth is the avoidance of spending $3.5 million to enlarge the sterile processing area within the surgery department. According to Mark Watson, president of the ACH Regional Network, surgeons were performing 12,000 operations a year, and the number of cases was increasing. (They performed 14,000 in 2010.) Sterilization technicians had a hard time keeping up, but expanding space and staff would have been a problem.
“Our surgery area is landlocked,” explained Watson, who first introduced the idea of lean Process improvement to the hospital. “In order to give sterile processing more, I would have to take away from someone else. So we started really looking at what was going on in the operating room, and we started with our flash-sterilization rate.”
The team decided this was the most urgent need — a flash sterilization rate of 10 percent was not acceptable, Watson said. (Flash sterilization is the immediate and unscheduled sterilization of instruments that have been dropped or otherwise contaminated during the surgery processes. It is a quality problem that creates variability and waste.) They scheduled a kaizen focused on reducing flash sterilization. The resulting improvements not only reduced flash sterilization to 2 percent, but also opened all the capacity needed to add an additional 4,000 surgeries a year.
“It was amazing what happened in the week-long program,” Watson said. “We fixed flash sterilization, and increased the capacity of the operating room to 16,000 cases. We invested in one flat-screen TV, and we took down one wall. We have a sterile processing department that could handle all the work that was there and more without expanding one square foot.
(Continuous-improvement ideas contributed by clinical coordinators from Akron Children’s Hospital Radiography School program)
“And now, we’ve done two capacity studies on surgery, and we are running at 64 percent. It will take 2.5 years, but we want to get to 85 percent efficiency, which would mean around $15 million in additional revenue in the same operating room with essentially the same people.”
Low-Tech Solutions Increase Customer Value
In addition to increasing the number of procedures, the hospital is focusing on patient Value in the form of decreasing wait times and increasing accessibility to doctors and services. This supports the goal of being the No. 1 choice for Northeast Ohio parents.
Outpatient doctor visits was an obvious place to start. If there is any customer who is most deserving of getting more from service providers, it’s a parent with a sick child. Emotionally drained and frequently exhausted, such parents Value predictability and kept promises. Less time spent at the doctor’s office means more time to take care of themselves and their families.
The doctors, nurses, and other employees at ACH’s Locust Pediatric Care Group know this. When deciding on a Process improvement goal, their focus was reducing the amount of time that established sick patients spend in the clinic. By its nature, the clinic is an unpredictable place as patients stream in from the city of Akron and surrounding urban and rural communities. Many of the children are poor, recent immigrants, or in foster care. All of them have potentially complex social and medical needs, and all of them receive care regardless of ability to pay.
Through a series of kaizens and A3-based project planning and implementation, the Locust team identified and implemented a number of improvements that reduced patient in-clinic time from 70 minutes (2009) to 43 minutes (2011). Significant improvements included:
- Converting paper charts to electronic medical records, which helped to streamline the information flow.
- Implementing visual whiteboards that track patient flow during the appointment.
- Adding a team-wide “huddle” at the start of the day to prevent problems, such as scheduling issues.
- Eliminating triage rooms — where patients would be evaluated for priority of care — instead using mobile triage carts in the exam room.
The team is working on more definitive documentation, but early feedback is that customer Value has increased.
“Office flow and access are the two biggest areas at Locust Peds where we can meet and exceed expectations from our patient families,” said Cindy Dormo, vice president for Pediatrics. “Now we’re measuring patient throughput and reviewing feedback from patients, which in the past has included complaints about long wait times, but is now turning favorable.”
Blue Belt Training Brings More People In
Dormo and other top-level executives said a key to the COE’s success is a focus on engaging all levels of the organization. Most recently, the COE team created a Blue Belt training program to focus on department and functional leaders, positions that would be considered “middle management” in a corporate setting. According to Dulin, the Blue Belt program is another example of how the COE program is directly supporting strategic growth goals.
“Our goal is to have this touch everyone. We then have everyone supporting the hospital’s goals, which then improves all of our major systems,” Dulin said.
Taking advantage of interest and enthusiasm generated by the MRI project’s success, the COE team chose the radiology department for the first Blue Belt training program. Every lead technologist, supervisor, manager, director, radiologist, the department chair and vice president participated.
Blue Belt participants learn how best to use the talents of their staff to streamline operations, improve the quality of care provided, and reduce variability and waste. Lessons focus on daily communication among staff members and leadership, learning how to track and improve daily metrics, and creation of standardized processes that stabilize patient flow.
The Blue Belt program is spreading to other departments. The plan is to begin with Dept. of Pediatrics employees, and then expand to surgical subspecialties, the Akron Children’s Heart Center, and Neurodevelopmental Sciences Center. In all at least 300 employees will have completed or been affected by Blue Belt training by the end of 2011.
Lessons Learned and a New Opportunity
Watson, the hospital executive who introduced continuous-improvement at ACH, identified these key factors as contributing to the COE’s early success:
Founding COE leaders: “After the decision was made to go with lean, I spent almost three months selecting people from our organization to help us on our lean journey,” he said.
Watson purposefully chose individuals who were successful, respected by their peers, and brought diverse backgrounds to the effort. These included a doctor with lean six sigma knowledge, a pharmacist who had just completed her Pharm.D., a medical technologist, a nurse, an M.B.A., and an administrator.
(From left, Dr. Mike Rubin, Dr. D. Scott St. John, Dr. Godfrey Gaisie, and Dr. Azam Eghbal from the Radiology Dept. hold their daily accountability meeting as part of continuous-improvement Blue Belt Training.)
Watson also stressed the importance of having a practicing physician on the team. When Dr. David Chand joined ACH after working as a consultant, he dedicated 20% of his time to the COE and the rest to seeing patients. His role in the CEO has since expanded to about 90% of his time, but he will always see patients.
“When you are dealing with physicians, in order to be considered part of the club, you really need to have a stethoscope and see patients,” Watson said. “They like to interact with other physicians who are seeing patients. That’s just the way it is.”
Chand has been invited to work on improvement projects in many areas of the hospital and has become the go-to man for other doctors interested in learning more about the COE, some of whom are in the Process of green-belt certification. His personal A3 projects have included removing non-Value-add time from the residents’ patient-rounding Process (daily in-person visits to patients).
Investing in education and training: Watson said an additional attribute that he looked for in team members was a quest for life-long learning.
After he assembled the team, Watson immediately sent them to a lean six sigma program at Johns Hopkins University, which included six weeks of learning over a four-month period of time (with project work done at ACH). The team then spent a week at Seattle Children’s Hospital to observe and learn from that CI program. In 2010, two team members received master’s degrees in operational efficiency and black belts from Ohio State University. Three others are now going through the course and will graduate in 2011.
Additionally, several department VPs have attended classes at Johns Hopkins and programs at Seattle Children’s Hospital.
“But we made a mistake,” Watson said. “When we started, we started with our front-line people working on projects with the A3 Process. And we had very good engagement from the executive level, vice president and above. But what we left out was that middle manager level.
“Now the middle managers are really enjoying and learning with the Blue Belt program. The A3 Process works much better now that we’ve covered the entire organization in terms of learning what we are doing. Our tagline is Process improvement through people development.”
Accepting failures/celebrating success: Not every project will be successful, Watson said, “and if they are all successful, you are not taking enough risks.”
ACH’s ambition is being noticed and rewarded outside of its own facilities. This year, it was awarded a contract by a third Cleveland hospital, MetroHealth Systems, to provide pediatric care in cardiology, gastroenterology, cancer and blood disorders, and critical care.
“We are impressed by how fully Akron Children’s is integrated into the region, how well it has partnered with other hospitals, and its growth, having added 77 individuals to its medical staff in
2009,” said Margaret Stager, chair of the Dept. of Pediatrics at MetroHealth. Previously, UH pediatric specialists were contracted to provide the services.
Akron Children’s Hospital Center for Operations Excellence
- Started in January of 2009
- Eight-week Lean six sigma Training designed for the people who do the work on a daily basis
- Projects are done on A3 paper using the DMAIC (Define, Measure, Analyze, Improve, Control) methodology
- Meet weekly for two hours of class time and one hour of coaching
Green Belt Program
- 10 Green Belts certified through Johns Hopkins Center for Innovation in Quality Patient Care
- 20 Green Belt candidates working on certification through Akron Children’s Hospital’s Green Belt Training Program.
- Candidates and projects selected by hospital leadership
- Ten days of training and project work spread out over five months using DMAIC methodology
- Tollgate session at the end of each DMAIC step
- Two-to-five-day rapid Process improvement events
- Strategically driven by hospital leadership
- Multi-disciplined teams that cross over Value streams
- Key stakeholders from the Value streams work together to solve problems and implement solutions
Blue Belt Program
- Manager/Leader Lean six sigma training for departmental certification
- Basic understanding of Lean six sigma principles and tools: gemba walks, daily huddles, Value stream maps
Akron Children’s Hospital: As the largest pediatric healthcare provider in northeast Ohio with hospital campuses in Akron and the Mahoning Valley, the dedicated team at Akron Children’s Hospital promotes the well-being of children now and in the future. We perform more than 600,000 patient visits each year at more than 85 locations. Our specialists care for infants, children, teens, and adults treating a wide range of conditions from routine primary care to the most complicated injuries and illnesses.
Akron Children’s earned the Gold Seal of Approval from the Joint Commission, as well as Magnet Recognition Status for nursing excellence from the American Nursing Credentialing Center. We are a major teaching affiliate of Northeastern Ohio Universities Colleges of Medicine and Pharmacy, and offer a number of pediatric subspecialty fellowship training programs. Our Rebecca D. Considine Research Institute is committed to advancing the prevention and treatment of pediatric illnesses and supporting the education and training of research staff. For more information, visit http://www.akronchildrens.org.
Learn more about lean six sigma in healthcare : Six Sigma Master Class – Improving Healthcare Processes
Lean production, six sigma, and total quality management have a shared history. While the ideas of Deming, Juran, and Shewhart gained wide acceptance and broad application in post-World War II Japan, the concepts of lean production, through the championing of Taiichi Ohno, also came to fruition. Lean manufacturing was initiated by Toyota during the 1920s by Sakichi Toyoda. In the late 1940s, Taaichi Ohno, a Toyota executive, achieved a great deal of success implementing the ideas originally conceived by Toyoda. During that time, Japanese manufactures were plagued with a variety of problems relating to quality and cost. Chief among them was the challenge of serving a prospering Japanese market that demanded more product variety.
At the same time, US markets and American manufacturers followed the traditional system of mass production, propagated by the success of Henry Ford. This system lent itself to large production runs and huge inventories. Its objective was to manufacture as many units, of a standard part, at a given time, in order to take advantage of economies of scale. This method of production encouraged employees to work faster, be less concerned with quality, and encouraged companies to hold massive amounts of work in process and finished goods inventories. As a consequence, companies produced massive amounts of waste. There was waste in terms of scrap, defects, warranty returns, wasted time, unnecessary movements of goods, unnecessary processing, along with the huge cost of working capital tied up in inventories. In addition, US companies were ill equipped to deal with product variety demanded by a market place growing more sophisticated. One solution to the problem was the application of total quality management; the other solution was the implementation of lean manufacturing principles.
What is Lean Thinking?
The lean approach refers to a company’s style of inventory management and operational effectiveness. Made popular by the Toyota method of production, also known as Total Productive Maintenance (TPM); lean thinking was given life in North America as a result of the work of MIT researchers lead by James Womack, Daniel Jones and Daniel Roos. The team of Womack, Jones and Roos introduced the term lean production to North America and the West with its 1990 publication of The Machine that Changed the World. In 1996 Womack and Roos produced another work that described the principles and applications of converting a mass production operation to a lean operation.
The book, Lean Thinking: Banish Waste and Create Wealth in Your Corporation, offers 5 guiding principles for practitioners:
- Determine value by-product/service offering.
- Identify value streams by each product and service offering.
- Make value flow.
- Let the customer pull value from the producer.
- Pursue perfection.
So, what is lean?
In our attempt to keep things simple, TPMG describes lean as:
- A method of management employed to minimize operational waste.
- A system of operation employed to deliver value added products and services to customers.
- A practice of producing goods just in time for customer order to keep the cost of holding inventory down.
- A company’s journey to eliminate the cost of operational waste from selling prices.
Lean production is fundamentally a manufacturing philosophy. It has been a popular manufacturing approach because it has empowered companies to produce more with less. Successful lean manufacturers have been able to produce more in less time, with less capital and fewer resources.
With respect to lean thinking, the objective for a company is to respond to customer requirements while establishing an optimum market price for its products and services. Lean practices become a strategic competence for a company when the elimination of its waste produces a circumstance by which the difference between a company’s average cost to produce a product and the product’s market price is significantly greater than that of its rivals. This difference provides a company with pricing power that can either drive excess profit margins for share holders or greater market share for the company.
To learn more about how your company can build a lean program, contact TPMG LLC.
To learn more about lean practices, visit: www.helpingmakeithappen.com
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