Monday, July 7, 2014

Focus and Leverage Part 361

In today’s posting, I want to return to the healthcare field and present a case study that I helped facilitate.  When I arrived, it was clear that patients, staff and physicians were highly dissatisfied with the amount of time it was taking for an ED admitted patient to be transferred to an in-patient bed.  In fact, patients were spending an average of 240 minutes waiting to be transferred to an in-patient bed from the time an admit order had been placed in the system, until they were actually transported to an in-patient bed.  Even though this hospital had set an internal goal of 120 minutes, only 32% of the patients had been transferred within this goal’s time.  So in today’s posting, I want to walk you through what this team did to overcome this issue.

The team first developed a project charter which had the following goal:

  • Reduce the average time patients wait in the ED before being transferred to an inpatient bed to 120 minutes with a percentage compliance within 120 minutes to be 70%
    • Improve responses to Press Ganey question, “What is time in ER before admitted”

The overall goal of this initiative was to reduce the average time that patients wait in the Emergency Department to 120 minutes at least 70% of the time. The natural consequence of achieving this goal would be an improved Press Ganey score for wait times in the ED before a patient is admitted. The team concluded that the operational benefits that could be achieved by reaching their goal included:

  • Increased patients, staff & physician satisfaction
  • Improved collaboration & communication between ED and inpatient nursing staff
  • Increased quality of care delivered to patients in inpatient setting

The team was trained in an integrated Theory of Constraints, Lean and Six Sigma improvement methodology with the focus being to identify the constraint for this admittance process.  Once the constraint was identified, they would focus their Lean and Six Sigma tools on it to exploit it to its fullest.  The team started my creating a current state process map which included a total of 89 steps, 18 phone calls and 20 hand-offs.  The team then characterized each step as either green (value-added), yellow (non-value-added, but necessary) or red (non-value-added waste).  In doing so, the team found that of the 89 steps, 20 of them were red and 1 was yellow. The team then created an Ideal State and a Future State map that resulted in a total of 42 steps. 9 phone calls and 10 hand-offs which they estimated would give them a new time of between 63 and 87 minutes, which would be well below their goal of 90 minutes.

Using an Interference Diagram, that I have written about before on my blog, the team discovered that the constraint in this process was the time required for housekeeping to clean and prepare the room for new patients.  After studying this problem, their solution was to assign at least two housekeepers to each room to reduce the time required to clean and prepare it.  Their solution was to be much like the workings of a pit crew at the Indianapolis 500 race, where the cleaners would be notified of which rooms needed cleaning and preparation prior to discharge of the current occupant..

One of the basic premises of the Theory of Constraints is that seemingly complex problems always require simple solutions and this problem certainly fit into this category.  Did the team reach their goal of 120 minutes?  They actually reduced the time to roughly 95 minutes (a 61% reduction) with plans in place to reduce the time by at least 20 minutes more.  Like I said earlier, complex problems require simple solutions.

Bob Sproull 

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