Healthcare Case Study Part 4

This is my final posting in this series of posts which includes the final results of this team's efforts.

This team did an excellent job of analyzing this important process and was able to remove much of the waste contained within it. But the real improvement came in the overall potential time to complete this procedure, which should have a significantly positive impact on damage to patient’s heart muscles when their recommendations are implemented, and this was the overriding premise and objective of this event.  Figure 10 is the final future state map for the Door to Balloon time and as you can see, the number of steps in the process was dramatically reduced!

                                    Figure 10 Final Future State Map

The following is a summary of before and after for this PVSA. The highlighted numbers in Figure 11 represents a summary of the actual cycle time reduction for Door to Balloon time, as well as reductions in the number of decision points and total steps in this process, which was a total of 27 steps. Another key element of this effort was a 31% improvement in the number of value-added steps.

Figure 11 Improvement Results Summary

Although a reduction in Door to Balloon (D2B) time of 13 minutes might not seem like much of an improvement to some of you, you must consider how much less damage to a patient’s heart muscle might be avoided. In the healthcare field for procedures such as Door to Balloon time, every minute counts.  As you have just observed, by combining Lean and Six Sigma with the Theory of Constraints, significant improvements were realized.  This hospital used what they had learned in this study to also streamline their surgical unit and were able to perform much needed surgeries on many more patients.

In my next series of posts, I'll begin a new subject.  Hope you enjoyed this series!

Bob Sproull

Healthcare Case Study Part 3

 

Continuing on with my healthcare case study.  The time data that had been collected was broken down into three separate phases of the D2B process: Door to EKG, EKG to Table and Table to Balloon. This was extremely helpful for the team in their efforts to identify the system constraint. As you can see in Figure 4 from my last posting, the EKG to Table Phase, with a mean value of 36.7 minutes, is clearly that part of the process requiring the most time and was designated by the team to be the system constraint. Table to Balloon time, at 21.2 minutes on average, also consumed a significant amount of time, while Door to EKG only required 4.75 minutes to complete. It is important to remember that this metric (D2B Time) was developed to capture median times rather than mean times, so hospitals are judged (and reimbursed) by a median time and are reported as such. The difference between the median and mean times for EKG to Table (i.e. median = 32 minutes and mean = 36.7 minutes) indicates that the data might be somewhat skewed and not perfectly normally distributed. This, of course, means that there are outliers that must be investigated for cause.

                                                Figure 5 Interference Diagram

After collecting and analyzing this data, the team was instructed to create two Interference Diagrams (IDs), one for Phase 2 (EKG to Table) and one for Phase 3 (Table to Balloon). You may recall from an earlier chapter that the purpose of the ID is to identify any barriers or obstacles (i.e. interferences) that stand in the way of achieving a goal or objective. In the cases for Phase 2 and 3, the goal was identified as reducing the time required to complete each phase. Figure 5 is the Interference Diagram created by this team for EKG to Table.

The following photo (Figure 6) was of the Interference Diagram created for the EKG to Table phase and is presented here only to depict what an Interference Diagram looks like for those of you who may never have used one before. The post-it notes contain a description of the interference with an estimate of how much time the interference might negatively impact the goal of reducing cycle time.  The Interference Diagram can then be used to develop and improvement plan on how to reduce the EKG to Table phase time.

Figure 6 Photo of ID

The team then used their fact-finding “walks” (i.e. observations and conversations) and the Interference Diagrams to create a SIPOC as demonstrated in Figure 7.  The team next developed a current state process map (Figure 8) and then completed a value assessment (Figure 9) of each step with green being seen as an acceptable process step with no improvement required.  Yellow indicates that the step in its current state needs improvement. Red indicates that the step is not adding value and needs to be either removed or improved dramatically!

                                        Figure 7 SIPOC Diagram

                                    Figure 8 Current State Process Map

Figure 9 is the Current State Map after completion of the standard value analysis, and as can be seen, the number of total red steps that exist was quite high.   The team next developed a future state map that reduced the number of decision points, swim lanes and hand-offs. This effort resulted in a dramatic reduction in the number of non-value-added (i.e. red) steps (i.e. 27 to 3).

                                    Figure 9 Current State Map after assessment 

In my next post, we will complete this case study.

Healthcare Case Study Part 2

 

Continuing on with my healthcare case study.  There was also a review of the basics of both Lean and Six sigma and how to combine these three methodologies into a single methodology. Figure 2 is a basic look at how these methods can be used together to generate improvements to any process or system being studied.  Remember, the Theory of Constraints identifies the focal point for improvement, while Lean works to reduce waste and Six Sigma reduces and controls the variation within the process.

Figure 2 Integrated TOC, Lean and Six Sigma

For whatever reason, the agency who developed this universal metric used the median rather than the mean. The current median standard for Door to Balloon (D2B) time had been set at 90 minutes, and this hospital was actually doing quite well against this standard with a median score of 66 minutes. However, because this hospital was anticipating the standard would be changing to 60 minutes in the future, they decided to be proactive by putting together a team of subject matter experts to look for ways to achieve this future target, before it was mandated to do so. In addition to this new time benefitting the patient (i.e. much less heart muscle damage), there was also a financial incentive for the hospital, in that reimbursement rates for Medicare and Medicaid patients are tied to completing the D2B time below the standard median time.

Figure 3 represents the first part of the D2B Time referred to as Door to Doc Time whereby the patient enters the emergency department and is eventually seen by a doctor for diagnosis.

Figure 3 D2Doc Time

After completing the training session, the team was instructed to “Walk the Gemba” by going to both the Emergency Department and Cardiology Department to observe what happens during this process and to have conversations with employees from both departments about problems they might encounter. This was a fact-finding mission aimed at understanding how patients are managed through this treatment process. The team collected many observations during this walk, most of which would be used to construct their Current State Process Map, which will be displayed shortly. Figure 4 is a high-level summary of part of their Gemba walk for Door to Doctor.

                                                Figure 4 High Level D2B Time

In my next post, we will continue with this Healthcare Case Study.