Mission Possible: Avoiding CPOE Pit Falls with Process Improvement Methodologies

1. Mission Possible: Avoiding CPOE Pit Falls with Process Improvement Methodologies

2. Hospital Profile • Located in Western Massachusetts • 212 Bed Community Hospital • 35,000 Emergency Room Visits Per Year • Hospitalist program

3. Holyoke Medical Center’s CPOE Objectives and Goals Introduction to Process Improvement Methodologies Physician Workflow Event Agenda

4. Inpatient Computerized Physician Order Entry (CPOE) Objective To redesign the physician work flow process by implementing evidence-based order sets and decision support tools that will reduce errors, improve efficiencies and communication by utilizing Information Technology.

5. Inpatient Computerized Physician Order Entry (CPOE) Scope • Laboratory, radiology, nursing, ancillary, and medication orders • eMAR (Med Administration Record) • Rules & Alerts • Medication Reconciliation • Zynx Orders Sets: Evidence-Based • Single Sign On

6. Inpatient Computerized Physician Order Entry (CPOE) Goal #1 Improve organizational communication and quality of information for clinical decisions. Goal #2 Reduce adverse drug events and medication errors by 75%. Goal #3 Improve accuracy and completeness of orders reducing Pharmacy and other Ancillary departments rework by 75%. Reduce unnecessary or redundant lab tests by 75%. Goal #4

7. The First Attempt at Process Improvement

9. Introduction to Lean Thinking

10. What is Lean Thinking? Lean ≠ Mean • or downsizing or outsourcing or working harder… • Rethink your entire operation • Simply, lean means using less to do more • Eliminate waste to optimize value • Concept of “Lean Management” associated with • the Toyota Production System

11. Respect for People Continuous Improvement Getting people to think and take initiative is the key! The Toyota Way Best Quality – Lowest Cost – Shortest Lead Time Best Safety – Highest Morale PDCA Learning Cycles (Continuous Learning Systems for Every Employee) John Shook 2005

12. Leadership and Communication at Toyota • Leaders are teachers and mentors – ask why 5 times? • All actions revolve around plan and problem-solving • “No problem is a problem” • Problems are opportunities to learn • For the system to work, problems must be exposed and dealt with forthrightly • No excuses vs. no blame – everyone reacts to problem – ask why not who • Tremendous reliance on individual initiative

13. Communication Effectiveness in Hospitals The Current State as demonstrated by the following 3 examples

17. Traditional Culture vs. Lean Culture Traditional CultureLean Culture Source: A.P. Byrne, O.J. Fiume

18. Why Lean in Healthcare? Healthcare is Like Base Jumping • Hospitalizations: 33.6 million/year • Deaths due to medical error: up to 100K/year • Deaths due to hospital acquired infection: up to 100K/year *Fixing Healthcare from the Inside, Today Steven J. Spear January 2006

19. The Need: The 8 Wastes Unused Employee Creativity Defects Inventory Over Production Waiting Material Movement Motion Extra Processing Lack of Training System Limitation Current Roles & Responsibilities No Standardized Work Office Layout Performance Measures Identifying Root Causes of Visible Waste

20. Preparing for Our CPOE Workflow Event Observations Developing Event Goals Team Selection

25. 2 Certified Lean Facilitators 3 Physicians: Medical Information Officer Hospitalist Private Physician Nursing Representation from all Ancillary Departments Meditech Total Participation: 35 Team Members Our Team

26. Your Mission If You Choose To Accept To identify work flow process and infrastructure issues to completely understand inpatient physician ordering and to help break down barriers prior to implementation. • Planning Communicating • Engaging Change management • Process improvement Overcoming resistance • Building trust Designing it right • Being flexible Being forthright • Testing Training • Nurturing Rewarding

27. Agenda

28. MD Ordering Process – Current State

29. Discharge Ordering Process – Current State

30. Typical Problems Observed in Organization Value: From the perspective of the customer Understanding Customer Requirements – Example: Not meeting timing needs Flow: No Waiting – No Rework – Information Available Many handoffs, Interrupts, Waiting for decisions and approvals Work: Standardized Built in Quality Significant Rework, Standards not being followed (workarounds) or no standard Manage, Improving and Learning: Milestones and Checkpoints, Learning Embedded Over processing, no management corrective action, limited feedback

31. What is a Lean Value Stream?   Valuable Flow No waiting No rework Information available from the perspective of the customer    Work Managing Improving and learning Standardized Built in quality Milestones and checkpoints Learning embedded

32. Making the Work Flow Step 1 Value Stream Chunks or Loops Apply basic Lean concepts Step 2 • Reduce handoffs by combining steps • Eliminate waiting for decisions with a “proceed unless halted” agreement • Maximize flow by managing interrupts Step 3 Apply Lean tools • Standard/balanced work – reduce variation in work • Visual workplace – identify problems (defects, backlog) • Built-in-quality – eliminate rework • Pull systems – a method to control process flow by replacing only what is consumed • Reduce handling, storage and paperwork • Production based on consumption

33. MD Ordering Process – Future State

34. Discharge Ordering Process – Future State

35. Creating the Future State

36. Creating the Future State

37. Creating the Future State

38. Organizational Will “The introduction of a CPOE system requires a shift in everyday practices of all members of a health care team. Change is daunting for many physicians, nurses and health administrators, which is why a clear understanding of CPOE and its benefits, possible drawbacks, and obstacles is necessary. An institution must overcome these barriers for a successful transition.” – Upperman JS et al. The Introduction of Computerized Physician Order Entry and Change

40. Questions? HMC

41. References Going Lean in Health Care, Innovations 2005, Institute for Healthcare Improvement Lessons from Toyota for Health Care?, John Shook, January 2006. Fixing Healthcare from Inside, Today, Steven J. Spears, January 2006