Friday, July 4, 2014

Focus and Leverage Part 359

In my last posting I told you that I would begin, again, with posts that are geared toward improvements in the healthcare field.  I thought about it and decided that maybe the best way to do this might be to share actual healthcare efforts that I have been a part of during my career as an improvement consultant.

The first healthcare case study that I want to present is something referred to in healthcare circles as Door to Doc time.  That is, the time it takes for a patient, who enters the hospital through the Emergency Department, to actually be examined by an ED physician.  The Door to Doctor time study identified that the medical screening had been occurring at the estimated average of 88 minutes. These extended times negatively impacts patient satisfaction, as reflected in Press Ganey scores and increase Length of Stay (LOS) for the patient.  Press Ganey is an external agency that tracks various metrics in the healthcare field (e.g. Door to Doc time, Length of Stay, etc.).  The level of scoring of various healthcare metrics, many times dictates things like reimbursement rates, so it’s important for healthcare organizations (i.e. hospitals) to attempt to drive these metrics in a positive direction.

By reducing Door to Doctor Time, patient satisfaction will increase and the time it takes for a patient to have a medical screening exam will decrease.  This hospital set two Strategic Goals for this improvement initiative as follows:
  • Strategic Goal  #1:  Improve Patient Satisfaction
  • Strategic Goal  #2:  Reduce Door to Doc Time

In terms of improvement to specific metrics, this hospital wanted to reduce the baseline average for Door to Doc Time from 88 minutes to less than 30 minutes and set a baseline average patient satisfaction score from its current average of roughly 70 % to greater than 85%.  Both of these were very ambitious goals to say the least.

The first thing we did was to provide training in the Theory of Constraints to the team so that the concept of identifying and managing the constraint within this process could be understood.  I did so with my traditional piping system diagram as depicted in the visual below.

This drawing depicts a piping system with different diameter pipes with water flowing through the system.  The team was asked to determine how they might increase the flow of water through this system and they correctly stated that in order to do so, the diameter of Section E would have to be increased.  TOC provides 5 improvement steps with the first two being to first, identify the constraint and then decide how to exploit, or make the most out of it.  I then translated this discussion into a real world example of an ED process as follows:

The team was then asked to identify the constraint in this process and they correctly identified the patient waiting to see the doctor at 45 minutes on average, once the preliminary work-up and triage is completed.  Knowing this, the team was instructed to focus their improvement efforts on the constraint first to reduce the time waiting in the ED room.  In doing so, the time the patient spends in the two waiting areas will automatically be reduced.

I then taught the team the concept of a little used tool called the Interference Diagram (ID) as depicted in the diagram below.  The ID is used to surface those things that get in the way of achieving the stated goal.

Once the team identified these interferences, they then selected those items that they felt would be high impact and relatively easy to implement and then implemented them.

The team also created a current state process map (with swim lanes) and color-coded them as Green, a value-added step, Yellow, a non-value-added, but necessary and Red, non-value-added.  This process map is depicted in the visual display below.

The team then proceeded to create a future state process map with as much of the waste as possible being removed.  The final results of this initiative were quite impressive as they separated two types of patients, bed on and bed off.  Since the original time was an average of both of these, it was not possible to demonstrate the before values, but the average time after the team implemented their solutions decreased the average Door to Doc Time from 88 minutes to 18 minutes for bed on and 42 minutes for bed off.  At the same time, patient satisfaction improved from an average of 70% to 84.6%.

The key to this improvement initiative was the team’s new knowledge of the Theory of Constraints.  The team learned that in order to improve a process, the most effective way to do so is to first, identify the constraint (bottleneck) and then to focus improvement efforts directly on it.  In doing so, significant results can be achieved in a dramatic reduction in time when compared to improvement efforts who don’t utilize the concept of constraints management.

In my next posting, we'll dive into another healthcare case study to demonstrate other improvement efforts and the results they obtained.

Bob Sproull

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