Beginning January 7th
I will be leading a team of hospital employees working on a problem in the Emergency
Department (ED) of their hospital. There
is a metric that is tracked which measures the length of time from when the
patient enters the Emergency Department until the medical screening exam begins
by the physician known as “Door to Doc” time.
The problem is that under the new Healthcare “rules,” if the wait times
are too long, then patient satisfaction scores will be negatively impacted. If patient satisfaction scores are too low,
then Medicare, Medicaid and private payers like Blue Cross and Aetna will reimburse
for services at a much reduced rate.
Door to Doc time is but one facet of patient satisfaction, but it’s
important from a patient satisfaction perspective.
Since 1986, with the passage
of the Emergency Medical Treatment and Active Labor Act (EMTALA), patient
volumes in emergency departments have increased significantly. Several different studies have estimated the
increase to be on the order of 40%.
Because of this increase, overcrowding and excessive wait times have
forced EDs to look at their processes to improve flow and reduce wait time. They’ve also been forced to provide more
complex and prolonged care to the point where sometimes ED patient’s health is at
risk. Because this new higher level of ED patients is straining the ED staff’s
ability to handle them in a timely manner and to provide timely and quality
care. As a result, even more delays are
being experienced by the incoming patients.
In anticipation of our
improvement event, the team leaders are busy collecting and analyzing pertinent
baseline data to be used by the full team to make improvements to patient flow
and satisfaction. As I’ve written about
many times in my blog, the problem to be studied is correlated with the actual
throughput rate of patients passing through the Emergency Department. It should be clear now to all of my regular
readers that the path this team will take will be to first, understand the
boundaries of our improvement effort and performance metrics we are trying to
improve. This will be accomplished by
reviewing the project charter that was created by the project champion. Once this is completed, the two Green Belts
and I will deliver “just in time training” to the full team so that the
concepts of things like process, constraints management, waste categories and
the improvement tools we will use during our improvement initiative will be
clearly understood.
The team will then “walk the
Gemba” so they have the information needed to create a SIPOC diagram and a current
state process map (or Value Stream Map).
The team will observe things like patient flow, estimated processing
times, where apparent waste exists, key hand-offs within this process, paper
work, wait times, patient queues, etc..
They will use all of this information to correctly identify the
constraint within the Emergency Department’s process from point of entry to the
beginning of the examination by the ED physician.
The team’s next step will be
to decide how to exploit the constraint by looking for ways to reduce waste and
variation within it by employing the principles of Lean and Six Sigma. The key to improving patient flow will be to
identify and focus the team’s improvement efforts primarily on the system
constraint, but will also look for ways to reduce things like the number of
handoffs, improve current communication mechanisms, waiting room times, etc.
during our effort.
There is an inherent danger
in isolating our improvement effort to only this specific part of this
process (i.e. Door to Doc). By limiting our “field of view” to this single
part of the patient value stream, we could create downstream problems. Improving
one part of a process will most surely improve the flow through the current
constraint, but a new constraint will arise as an effect of the improvement
effort. For example, when the team is
successful in reducing the Door to Doc time, the velocity of patients moving to
the next step in the process will be higher and could cause a queue of patients
waiting for things like test results to come back or even the physician’s
decision on whether or not to admit the patient. If the decision is made to admit the patient,
then the new constraint could even be the discharge process that frees up beds
in the various hospital units. In the
world of TOC, improving a singular part of the process without considering the
overall impact on the total system is known as a localized improvement.
Once the Gemba Walk has been
completed we will develop a SIPOC to get a 10,000 foot view of our
process. When we are satisfied with our
SIPOC we will then create a Current State Process Map with swim lanes listing
all of the activities used to move a patient through this process. The team will then perform a value stream
analysis by color coding each activity in the process as either value-added
(Green), non-value-added but necessary (yellow) or non-value-added (red). We will then create an ideal state map by
removing all of the non-value-added activities.
Finally, we will create a future state map that will lie somewhere in
between the current state and the ideal state maps. The future state map will identify all of the
needed changes to the current process and should significantly improve the flow
through the door to doc process.
The final stage of our
improvement effort will be to develop an improvement plan, based upon how we
see our future state process. The plan
will consist of Just Do Its, potential
Rapid Improvement Workshops that
might be needed as a result of this new process, potential additional Value Stream Analyses recommendations
and possible DMAIC opportunities
needed to reduce variation. The Just Do
Its will typically be tied directly to the creation of the team’s recommended
Future State Process Map. The team will
then present their findings and recommendations to the executive staff and
process owner(s) to gain their buy-in.
It should be a “fun” week
and when it’s completed I will report the team’s findings and recommendations here
on my blog.
Bob Sproull
2 comments:
Bob, I wish you and your team good luck in all this. Health care is a huge expense in national budgets. Improving the flow of patients while improving the quality of their care are two actions needed around the world. So your study could have a great effect not only on hospitals in the US, but in those around the world.
John, thanks for your comment. I believe healthcare in general is at a very important junction and without changing direction both quality of care and costs will continue to deteriorate. By integrating TOC with LSS (a.k.a. TLS) patient throughput can accelerate significantly without a corresponding increase in operating expense. Stay tuned for more and thanks again for your comments.
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