| Background | | | | - Red - Not used, should be reviewed to see if |
| This VA Hospital is a small facility focused on the | | | | another department needs it and if not thrown |
| Primary Care, Rehabilitation and Mental Health | | | | away |
| needs of its Veteran-Patients. Most surgeries and | | | | We worked on 2 exam rooms and the hallway. |
| other specialties are handled at the larger regional | | | | The hallway had 9 bulletin boards with random |
| hub medical center. | | | | information. Both exam rooms were set up |
| Given the focused mission of this smaller medical | | | | differently and didn't have a list of instruments, |
| center they decided to focus Lean Six Sigma on | | | | supplies and pamphlets (patient information). |
| improving patient service in Primary Care. The | | | | To see 5S before and after pictures goto and |
| quality of care in this medical center was | | | | view the White Paper page. |
| excellent, but seeing patients at their appointment | | | | We completed the 5S's by labeling everything that |
| time was poor. Only 9% of patients were seen | | | | needed to be in the room and creating a standard |
| on-time for their primary care appointment. This | | | | list of instruments, supplies and pamphlets that |
| caused stress for patients and for the healthcare | | | | each room should always have. We removed |
| providers (Support Staff, Nurses and Physicians). | | | | every bulletin board in the hallway, except the |
| Project Overview | | | | one by the phone, which got an updated internal |
| - Initial Assessment | | | | phone list and emergency numbers. |
| - Performance Scorecard | | | | The exam room standardization is sustained by |
| - 5S Visual Management | | | | making the standardized supply list part of the |
| - Spaghetti Diagrams | | | | monthly housekeeping and safety audit. |
| - Time Study / Quickchangeover | | | | Spaghetti Diagram Once the foundation of Lean |
| We used a variety of Lean tools, over an 8 week | | | | was in place, with the Performance Scorecard and |
| period, to improve on-time delivery of care to | | | | a visually organized workplace we began to |
| patients. Each one will be covered separately. | | | | analyze the Primary Care Exam process. To do |
| However, before we go into the details, I will | | | | this we used two Lean tools, Spaghetti Diagrams |
| cover how we decided to use the tools show | | | | and Quickchangeover Time Study. |
| above. An initial assessment of the department | | | | Lean is a series of tools to identify and eliminate |
| showed three problems. | | | | non-value-added activities. Spaghetti Diagrams |
| The first was a lack of awareness of how the | | | | track people movement during a process. We use |
| department was performing. Doctors, Nurses and | | | | it to find excess movement of the people in the |
| support staff worked all day, went home and had | | | | process. In this case we were tracking the Nurse, |
| no idea how the overall department had | | | | Patient and Physician. The outcome of the |
| performed that day. They know how they did, | | | | spaghetti diagram is to rearrange the physical |
| and how their patients were feeling, but there | | | | workplace to reduce non-value-added move time. |
| was no connection with the overall Primary Care | | | | Even after implementing 5S Visual Management |
| organization. Everyone worked in their own silo. | | | | and organizing the rooms to have all the |
| The second problem was a general lack of | | | | instruments, materials and pamphlets, there is |
| organization and standardization in the workplace. | | | | excessive movement in and out of the room. |
| The hallways were cluttered and every exam | | | | The Primary Care Exam process has created too |
| room was set up differently. It was hard for | | | | much movement for the Nurse and Provider. |
| patients in wheelchairs to maneuver around | | | | The Spaghetti Diagram also showed that the |
| hallway obstacles. Providers had to walk around, | | | | room is too big. Almost half of it is unused by the |
| from room to room looking for instruments and | | | | providers or patient. If we could rebuild the |
| information. | | | | Primary Care Department we would make the |
| Finally, there was an on-time delivery of care | | | | rooms smaller to improve space utilization, fitting |
| problem due to rooms being used for exams, | | | | more exam rooms into the same envelope. If |
| longer than scheduled. The department was | | | | you recall from the Assessment, a lack of exam |
| properly staffed, and technically has enough | | | | rooms being available was key driver for poor |
| space, but there was often a lack of rooms | | | | on-time-delivery of care. During a facility |
| available when a patient was ready scheduled to | | | | expansion later that year, this was acted on and |
| be examined. | | | | the exam rooms were halved in size and doubled |
| Consequently, patients were rarely seen at their | | | | in number. |
| appointment time. Not seeing patients on time | | | | A picture of the Spaghetti Diagram is shown on |
| caused them to wait longer and leave the exam | | | | the same white paper as mentioned above. |
| later than expected. This resulted in a culture of | | | | Quickchangeover Time Study Analysis At the |
| inefficiency, disorganization and a lack of timeliness. | | | | same time as we were drawing out the |
| Patients learned to come late to appointments, | | | | "spaghetti" of people movement we were time |
| because they knew they wouldn't be seen on | | | | studying what was happening during the exam |
| time. Providers got frustrated at the lack of | | | | process. |
| organization in the workplace and had to stay at | | | | This Lean tool is called Quickchangeover. Its |
| the hospital longer than their normal shift | | | | outcome is getting the patient in and out of the |
| Performance Scorecards Lean is a set of tools to | | | | room faster, while improving the quality of |
| identify and eliminate non-value-added activities. It | | | | service. Quickchangeover uses time study analysis |
| creates visibility. The first step in our Lean | | | | to understand if there are times when the patient |
| journey was to create visibility. The Lean Team | | | | is in the exam process that is wasted time for |
| (Doctors, Nurses, Support Staff) created the | | | | them. We want to know what exactly is making |
| Primary Care Performance Scorecard. This | | | | the exam take longer than scheduled, so we can |
| scorecard represents a few key performance | | | | improve on-time-delivery of care and make sure |
| indicators. | | | | that patients are seen on time. |
| You will notice that there are just five measures. | | | | Our time study is shown below in seconds and |
| The fewer the number of measures, the more | | | | minutes. |
| focus each one gets. | | | | Time Study Analysis |
| We started with the Purpose, or Mission, of the | | | | - Nurse calls patient - 38 seconds (0.6 minutes) |
| Primary Care department. The team then | | | | - Weigh in - 27 seconds (0.5 minutes) |
| brainstormed their key performance measures. | | | | - Previsit with Nurse - 204 seconds (3.4 minutes) |
| We weighted them to show which measures are | | | | - Review reminders with Patient and put in |
| most important in achieving the Mission. Finally, we | | | | computer - 129 seconds (2.2 minutes) |
| gave each measure a "Below" and "Exceed" goal. | | | | - Physician review history with patient in the room |
| This Scorecard is reviewed by the head of | | | | - 740 seconds (12.3 minutes) |
| Primary Care each month with the entire Primary | | | | - Patient exam - 914 seconds (15.2 minutes) |
| Care staff. It is a 15 minute meeting to review | | | | - Physician does exam data entry - 1062 seconds |
| prior month and year-to-date performance. | | | | (17.7 minutes) |
| Primary Care Department Scorecard Complete | | | | - Complete reminders with patient - 20 seconds |
| Clinical Reminders | | | | (0.3 minutes) |
| Exceed Goal = 90% | | | | - Physician leaves - 102 seconds (1.7 minutes) |
| Weighting = 35% | | | | - Nurse enters - 32 seconds (0.5 minutes) |
| Current Performance Y-T-D = 50% | | | | - Nurse reviews what Provider said - 175 seconds |
| Patient Service Survey % Excellent responses | | | | (2.9 minutes) |
| Exceed Goal = 90% | | | | - Nurse does patient care as ordered by Physician |
| Weighting = 30% | | | | - 937 seconds (15.6 minutes) |
| Current Performance Y-T-D = 85% | | | | - Patient leaves, room readied for next patient - |
| Utilization of Access Appointments | | | | 136 seconds (2.3 minutes) |
| Exceed Goal = 95% | | | | - Total Time = 75 minutes & 16 seconds |
| Weighting = 15% | | | | There is one major finding of this analysis and it |
| Current Performance Y-T-D = 78% | | | | had a big positive impact. The Physician was |
| 1st Patient of the Day Roomed and Ready by 8 | | | | spending 17.7 minutes entering data into the |
| AM | | | | computer with the patient in the room. This is |
| Exceed Goal = 95% | | | | called "Completing the Encounter" on the time |
| Weighting = 10% | | | | study below. The patient does not need to be |
| Current Performance Y-T-D = 67% | | | | there, but the Physician wants to enter this data |
| 1st Patient of the Day Seen by Physician by 8 | | | | as soon as possible after the exam and usually |
| AM | | | | doesn't have access to another computer. So the |
| Exceed Goal = 95% | | | | patient sits and makes small talk, while the |
| Weighting = 10% | | | | Physician enters data. |
| Current Performance Y-T-D = 61% | | | | The team's solution was to make one room in |
| This is the scorecard, six months after we | | | | the Primary Care department a computer data |
| completed the project. Note, our project worked | | | | entry room for Physicians. This would cut 17.7 |
| primarily on the two on-time-delivery measures. | | | | minutes out of the exam process for the patient |
| While still far below the goal of 95%, both | | | | and the exam room. With well over 100 exams |
| measures increased from below 10% to the | | | | per day, this gives back the equivalent of 4 exam |
| levels shown above. | | | | rooms per day. |
| 5S Visual Management | | | | Results |
| - Sort | | | | - Improved on-time delivery of care from 9% to |
| - Set-In-Order | | | | 61% in 6 months |
| - Shine | | | | The cumulative effect of this Lean Project was a |
| - Standardize | | | | drastic improvement in seeing patients at their |
| - Sustain | | | | appointment times. While still below the goal, |
| We first addressed the physical disorganization | | | | improvements continue to be made in this |
| using 5S Visual Management. The first step in the | | | | Hospital's Primary Care department. They are |
| 5S Visual Management system is to sort through | | | | currently experimenting with: |
| everything in the workplace to determine if it is a | | | | - Staggering breaks |
| Green, Yellow or Red item. | | | | - Starting half the appointments at 7:45 AM |
| - Green - Used frequently, needs to be easily | | | | - Adding evening hours |
| accessed | | | | All of these ideas are part of the process of |
| - Yellow - Used, but infrequently, can be stored in | | | | increasing room availability and seeing patients |
| a storeroom | | | | on-time. |