Michael Blatchford, Consultant Health Roundtable

1. Long Stay Patient Workshop October 2010 Michael Blatchford, Consultant Health Roundtable

2. Sometime work feels like this

3. This Sessions Objectives How Lean Principles can be used to rescue the Stranded Patient How to selecting the right patient type How to conduct a Waste Audit How to measure the Stranded Patient How to use Practical Problem Solving How to use Value Stream Mapping

4. Warning – parts of this presentation are like a Keystone Bridge

5. Current State

6. Lean Thinking Framework for Long Stay Patients Workshop One (2 days): 1.1Intro & Eight Wastes and Long Stay Registry 1.2 Aims & Measures 1.3 – 1.4 Value Stream Mapping 2.1 VSM – People Engagement 2.2 VSM Validation & Pt Story 2.3 5S 2.4 Planning  Workshop Two (2 Days): 3.1 Report Back 3.2 Problem Solving 3.3 – 3.4 Push Pull Simulations 4.1 Future State Map 4.2 Leveling and Queue Reduction 4.3 People Engagement 4.4 Action Planning Weekly 20 Minute Teleconferences Workshop Three (2 days):   5.1 Report Back 5.2 Visual Workplace 5.3-5.4 Standard Work 6.1 Mistake Proofing & Quick Changeovers 6.2 & 6.3 Sustainability 6.4 Action Planning Sustained change

7. Select Aim Statement Within 6 months, the nos. of acute # NOF patients with an average LOS >21 days will decrease by 50%. 100% of stroke patients will have a length of stay less than 21 dayswithin 6 months. To reduce palliative care patients with LOS above 30 days to 0 overa six month period. By May 2011, we will ensure no craniotomy patient remains as an inpatient beyond 21 days unless their neurosurgical condition dictates this. To reduce the hospital length of stay of the colorectal stranded patient by 30% over three months.

8. Waste Audit Waiting Overproduction Rejects Motion Processing Inventory Transport Staff Utilisation

9. Exercise 1: Waste Audit Write the Number for the waste Write the Letter for the waste Write the estimated time lost on the waste Write the identified waste as a question

10. Waiting Understanding Waste For people, signatures, and/or information is waste. This is “low hanging fruit” which is easy to reach and ripe for the taking. • Waiting in ED to be seen, waiting to be admitted • Excessive signatures or approvals • Dependency on others to complete tasks • Delays for test results Waiting - delays for PEGS, CT scan, echocardiograms, angiograms, families to make decisions/consent/meet, ACAT team, Limited weekend services

11. Understanding Waste Overproduction Producing work prior to it being required is waste and is the greatest of all the wastes • Meds given early to suit staff schedule • Testing early to suit lab schedule • Producing reports no one needs or reads • Batch processing – scripts, referrals, pharmacy protein drinks Overproduction- rehab & ACAT assessment too early

12. Understanding Waste Rejects An adverse event with serious consequences occurs in about 15% of overnight stays (Jackson, Duckett et al 2006, J Health Serv Research 11:21-6) Refers to all processing required creating a defect or mistake and the additional work required to correct it • Adverse Events (sentinel events, medication errors) – • Wrong or missing patient information • Forwarding partial documentation to the next process • Lost files or records • “only 10% of the time is everything right when we go to theatre” Rejects – falls & assoc injuries, NGT dislodgement & replacement assoc Xrays, nosocomial infection,

13. Understanding Waste Motion Any movement of people, paper, and/or electronic exchanges that does not add value is waste • Searching for patients • Searching for work documents • Searching for medications • Searching for computer files on your desktop • Hand-carrying paper work to another process • Searching for poorly located supplies • Walking to equipment that is not centrally located Cost of orderly to transfer & nurse to escort – taking nurse away from other allocated patients

14. A Sad Error Understanding Waste

15. Understanding Waste

16. Understanding Waste More Motion Waste

17. Understanding Waste Processing Putting more work or effort into the work required by internal or external customers is waste or doing the steps in the wrong order • Duplicating tests, reports or information – 25 Funct. Asx • Ordering more diagnostic tests than the diagnosis warrants • Completing excessive paperwork – Obstetric Theatre 5 copies • Entering repetitive data / information – Multiple Demographic Histories Processing- new assessments by rehab allied health staff when acute staff have done same, completion of multiple referral forms with same information, No single CVA AH team from admission to d/c [ED/Acute/rehab]

18. Processing Understanding Waste

19. Understanding Waste Inventory Work piles, excessive supplies, and excessive signature requirements are waste • Duplicate medications and supplies in excess of normal usage – 15K excess dialysis fluid • Files awaiting tasks completion or approval by others • Extra or out-dated manuals, newsletters or magazines • Purchasing excessive office supplies • Obsolete files, and equipment • Insufficient cross-training of staff

20. Understanding Waste Transport The extra or unneeded time element associated with the delivery of work to a process Patient visits 15 locations in 1 antenatal visit! • Transporting patients to surgery prematurely or unnecessarily moving them around • Moving samples, specimens, documents, equipment early /late or to the wrong location • Delivering documents that are not required • Excessive filing of work documents Transport- moving between several wards, to & from Radiology

21. Understanding Waste Staff Utilisation Is a result of not placing people where they can (and will) use their knowledge, skills, and abilities to the fullest • Not using staff ideas – move the in tray • Not maximizing staff time on core tasks • Project deadlines not being met • High absenteeism and turnover • Inadequate performance management system • Incomplete job skill assessment prior to hiring

22. AHA Moments Heavenly Mail box Consolidation of paper work Cluttered workspace Dedicated staff area Multiple spots of linen storage Sensitive literature relocated “That is hideous”

23. 8 Wastes

24. Benefit Vs Effort

25. Daily Measurement

26. Issues Log

27. Issues Log

29. Practical Problem Solving

30. The Health Roundtable A3 PRACTICAL PROBLEM SOLVING ( PPS ) TEAM MEMBERS DEPARMENT / AREA DATE PROBLEM DEFINITION FISHBONE ANALYSIS TOP 3 MAN MACHINE METHOD WHAT – STANDARD – WHERE – WHEN – EXTENT - 1 2 3 MATERIAL MEASUREMENT ENVIRONMENT 5 WHY ANALYSIS TOP 3 WHY – BECAUSE – WHY – BECAUSE – WHY – BECAUSE – WHY – BECAUSE – WHY – BECAUSE – WHY – BECAUSE – WHY – BECAUSE – WHY – BECAUSE – WHY – BECAUSE – WHY – BECAUSE – WHY – BECAUSE – WHY – BECAUSE – WHY – BECAUSE – WHY – BECAUSE – WHY – BECAUSE – POINT OF CAUSE PROBABLE CAUSE - COUNTERMEASURE ACTIVITY CONTAINMENT ACTIVITY ACTIVITY CHECK PERIOD DATE ACTIVITY CHECK PERIOD DATE WHO WHO PART DAY WK PART DAY WK ROOT CAUSE -

31. Cause and Effect Diagram • Identify the problem on the right hand side • Brainstorm the potential causes of the problem on the left hand side • Evaluate each cause – frequency, severity

32. Results from fishbone exercise – those item highlighted in red are the quick wins already achieved.

33. 5 Whys

34. Exercise 2 – Practical Problem Solving Using the A3 Practical Problem Solving handout, fill in for your DHB Long Stay Patients

35. Value Stream Map – current state

36. Value Stream Map – current state THE 7 STEPS Identify the Value Stream (“patient perspective”) and collect Patient and Staff Stories (“Bubbles”) Identify Process Steps in the Journey (“Boxes” ) - green Document Key Tasks within Each Step - yellow Estimate Delays and Queues between Steps - red Show Patient flow Identify Supporting Flows of Info, Staff & Materials - blue Estimate Total Value Added and Wasted Time

37. Value Stream Map – current state

38. Value Stream Map Walkthrough Lots of paper work shuffling from GP to admission. Where does the patient and carer fit in? There is a well defined process up to day 8 to 10 Where does the MDT fit in? Surgery happens on a Monday but best case LOS is Tuesday, so where to they go when the inn is full? We move patients out of 3E on day 6, and this is where issues may arise, no plan, unfamiliar patient and procedure, outlier issues. From day 10 on reduced planning, all related to symptom control, are we trying to fit a square peg into a round hole?.

39. Value Stream Map – Future State 1) Elective day surgery and OT 2) Elective day surgery and OT combined 3) Emergency and OT

40. 1. Produce to your Takt time 2. Develop one piece flow wherever possible 3. Use pull and kanbans to control the process if one piece flow does not exist upstream 4. Try to send the patient schedule to only one process step (as close to the end as possible) 5. Distribute the treatment of different patients evenly over time at the pacemaker process (start with the greenstream) 6. Create an “initial pull” by releasing and withdrawing small, consistent increments of work at the pacemaker process (to meet system takt time) 7. Develop the ability to handle “every patient need every day” (then every shift, then every hour) in treatment processes upstream of the pacemaker process Value Stream Map – Future State

41. Takt Time This synchronizes the flow in the hospital to match the patient demand Takt time = available working time per day patient demand per day Long Stay Stroke Patients 217 patients per year 365/217 = 1 patient every 1.68 days or every 40 hours

42. Batching Vs One Piece Flow Palliative Care Ward Weekly 90 minute MDT meeting with 20 staff Vs Mon, Wed, Fri 10 minute meeting with 6 staff Surgical Ward Weekly Consultant driven discharges Vs Daily event driven discharges (Nurse led on weekends)

43. Push Vs Pull Palliative Care Ward Ward tries to Push patients into aged care facilities Vs A Nurse Practitioner, GPs and medical support work with aged care facilities to provide palliative care in the aged acre facility. The aged care facilities now look into ward and pull appropriate patients

44. Value Stream Map – Future State 1) Elective day surgery and OT 2) Elective day surgery and OT combined 3) Emergency and OT

45. Proposed Key Changes 1) New admission process Flag potential Stranded Patients MDT pre admission assessment EDD allocation Event driven visual pathway 2) New hospital process Emergency theatre session slots Community referral EDD allocation and evaluation 3) New discharge process and community process Discharge 2 by 10am Patient flow whiteboard and MDT daily meeting Patient updates event driven visual pathway Community liaison pulls referrals

46. Quantitative and Qualitative Outcomes

47. Quantitative and Qualitative Outcomes

48. Quantitative Outcomes

49. Acute # NOF patients with LOS > 21 days

50. BOP– Lean Team Discharge Plan