Process Improvement Anyone Can Do: Basic Tools and Concepts

1. Process Improvement Anyone Can Do:Basic Tools and Concepts Karl B. Palmer, RN Rural Quality Program Conference Washington, D.C. September 2, 2009

2. Located in Menomonie, Wisconsin Approximately 40 providers, all employed by the Medical Center Provider-Based Clinic (department of a 25 bed Critical Access Hospital) Population Served Primary Service Area = 40,000 people Approximately 1,000 known, diagnosed diabetics within project age ranges Predominantly Caucasian with a notable small population of Southeast Asian (Hmong) and a very small population of Hispanic agricultural workers Outpatient services include Family Practice, Internal Medicine, Pediatrics, OB/GYN, Podiatry, Occupational Medicine, Orthopedics, General Surgery, Sleep Medicine, Behavioral Health, and Physical Rehabilitation Red Cedar Medical CenterMayo Health System

3. System of Care One of 12 organizations that make up Mayo Health System, part of Mayo Clinic Mayo Health System is a strongly collaborative system with monthly system-level diabetes team phone meetings representing all 12 sites Mayo Health System has an active Diabetes Expert Team represents multiple sites and multiple roles Mayo Health System supports local and system-level transparent sharing of diabetes data

4. Just a Bit About Me • Bachelors Degree in Nursing • Pursuing Masters of Science in Nursing and Healthcare Systems Administration • Seven years bedside critical care nursing • Three years Associate Director of Clinic Nursing • Received training and experience in Six Sigma, LEAN, PDSA methods, team leadership/project management, emergency preparedness, staff supervision • Quality Nurse Specialist at Red Cedar Medical Center-Mayo Health System • Outpatient Diabetes, Ambulatory Care Quality, Patient Safety, and LEAN • Nurse Co-Vice Chair of Quality for Mayo Health System • Project management, System-level Medication Reconciliation Workgroup lead, Co-lead Quality EMR Integration Team (current focus on building and implementing Computerized Physician Order Entry and Order Sets), sit on Mayo Clinic Nursing Quality Committee Moral of the story: I am no different than most of you…some classes and coursework, but the majority of my process improvement education Has been learn by watching and doing.

6. Tools We Have Used, That You Can Too! • Flow chart • 5-whys • Inter-relations diagram • Impact wheel • Associative problem solving • PDSA • Matrix

7. Why are we doing these things? • The needs of the patient come first. (Mayo Clinic Primary Value) • To provide ideal care- Exactly what the patient needs, when they need it, not more, not less, customizable to the individual patient, at continually lower cost. (Dr. John Kenagy) • To provide care that is Safe, Effective, Patient-Centered, Timely, Efficient, and Equitable.(The Institute of Medicine)

8. Reality Check…Culture eats process for breakfast!

9. Flow Charting • Why: To better understand the current state of affairs (or possibly plan future processes) • Keep it simple- just visually represent a process • Follow the Jimmi Hendrix principle - When flow charting, stay as high as you can as long as you can (Charles Liedtke, Strategic Improvement Systems, LLC) • Ideally, you will base your current state flows on observations of the actual work (Gemba); observation is always more “real” and accurate than meeting room memories • If unable to observe, use multiple experts, and ask several people to create or validate the process flow. Often there is not one process (which may be the root cause of your problems).

10. Comments on Flowcharting • You can flow • Work (people, activities) • Information • both • Use to identify value added steps (For the patient! Remember why we do this stuff!) and reduce waste to make the process efficient • Think of how you can create continuous flow, instead of batch flow. • Pull vs Push Flow

11. Simple Visual Flow Based on the Adaptive Design concepts of Dr. John Kenagy

12. Basic Formal Flowchart Symbols Start or End Activity Decision or Question Off Page Connector Activity Document Delay Start or End

13. An Actual Example Illness, Injury or need for care (v=variation was noted during this process step) Pt calls RCMC (V) Need/Resource Match (V) Pt waits for ED Pt Waits for U/C Pt Waits for Clinic Pt roomed Pt roomed Pt roomed Pt waits Pt waits Pt waits Medical Care or Patient Re-Triaged by Provider (V) Medical Care or Patient Re-Triaged by Provider (V) Medical Care or Patient Re-Triaged by Provider (V) Patient leaves Patient leaves Patient leaves

14. The Message: Don’t Be Afraid of Flowcharting! JUST DO IT!

15. 5 Whys • Find the root cause of a problem • 1st order problem solving = band aid fix, happens day after day • 2nd order problem solving = fix the cause, problem gone for good • Helps keep you from jumping to conclusions • If you need help asking why 5 times, find a 5 year old!

16. Example Preventive and chronic disease care is missed during visits Why? Provider rushed Why? Patients are late, disrupting schedule Why? Because they come in the wrong entrance Why? Because there is no external signage telling them which door to use First Order Problem Solving- Tell patients to come earlier Second Order Problem Solving - Improve external signage.

17. Patient Leaves from Walk-In Encounter Why? Wait is too long Why? -Not enough clinic openings -UC busy Why? Why? -Lack of MD/PA in clinic -Meetings -Hosp -Sched ule full Why? -Done -see 2b -see 2c -Too many off -Long term absence Why? Why? -No enforced rules -see 2a Why? (2a, 2b, and 2c are additional 5 why branches) -Rules old -0 buy in Why? Why? -Not reviewed -What’s in it for me? Why? Why? -No one responsible -Value on family time -Done Effective solution from this 5 Why-Form a responsible provider Access Committee to create and maintain staffing guidelines

18. Now, we try it with your Problems!

19. Inter-relations Diagram • Helps you sort through and prioritize multiple causes or issues • Handy if root cause process like the 5 whys has multiple branches and you are unsure of where to focus (especially with limited resources) • Often based on opinion - If you have solid data on all items, consider a Pareto chart.

20. How it works • Put your issues in a rough circle (Post-its work well on chart paper) • Go around the circle of issues one at a time, and consider direction of impact or causality (or lack of relationship) • Represent the direction of causality with an arrow.

21. Interrelations Diagram for Preoperative History and Physical Problems Chart Patient Transcription Dictation Routing Scheduling Off-Site The more arrows coming OUT of a category = more likely to be a main driver in process/problem. (Usually a good “bang for your buck” to start there) The more arrows going IN to a category may be an ideal place to focus measurement to show improvement.

22. Lets Try It • Financial Problems (High number of uninsured or underinsured patients, high volume of patient charges written off by medical center) • Medication Compliance Problems (Patients not compliant with filling or taking diabetes medications) • Lab Compliance Problems (Patients not having recommended diabetes lab tests in recommended timeframes) • Visit Compliance Problems (Patients not coming for diabetes visits)

23. FINANCIAL MEDICATIONS LAB VISITS

24. 3 Out, 0 In Primary Driver FINANCIAL MEDICATIONS LAB 1 Out, 2 In 0 Out, 3 In VISITS 2 Out, 1 In

25. Impact Wheel • Use to consider potential consequences of change. • Useful to help make decisions when there is significant risk or resource required to test a change. Use some caution, however, as this is completely abstract thought, not reality. None of us can tell the future! • May help you avoid costly (monetary, cultural, regulatory) mistakes.

26. How it Works • Write down the proposed action step in the center • Write down the expected positive and negative results of that step around it • For each result, write down the positive and negative effects around it • Continue this process as long as it is helpful • Color-coding levels of impact may be helpful

27. Patient outcomes improve + Impact Wheel Statistics (process measures ) improve + Budget Cuts - Docs have info to make clinical decisions + Layoffs - More patients will Come in for testing + Revenue Decreases - If we stop charging low income patients for lab tests, then… Medicare could cite us for “enticement” - We could lose certification - We could lose reimbursement -

28. Lets Try One • What if your hospital/clinic only offered vegetarian food choices in the employee cafeteria?

29. Staff feel tired - Cafeteria unable to sustain vegetarian-only menu Cafeteria revenue drops - Less staff Will eat at work- Profit margin for cafeteria Will decrease - If we only offer vegetarian food for staff, then… Morale will improve + Employee obesity levels will go down + Employees will feel healthier + Lower premium prices over time + Less health insurance claims +

30. Associative Problem Solving • Very unique method of getting teams to think outside of the box • Can unlock the creativity of employees

31. How it Works • Start with the problem • Have group take 5 minutes, and write down how they would solve the problem if they were someone else (you select the alternate identity) • After the time is up, go around the group and capture all unique ideas • All ideas are okay-impractical, immoral, illegal, etc.

32. Problem: patients not coming in for recommended diabetes visits • How would Oprah solve this? • How would a 5 year old solve this? • How would a pro football player solve this?

33. Patients not coming in for recommended diabetes visits: What would Oprah do? • Send a limo • Build a clinic closer to the patient’s house • Send a doctor to the patient’s house • Do Oprah’s book club on a diabetes book so that millions of women read it and realize the importance of visits Far fetched?

34. Patients not coming in for recommended diabetes visits: What would Oprah do? • Send a limo (offer taxi vouchers) • Build a clinic closer to the patient’s house • Send a doctor to the patient’s house (outreach activities, partner with public health or nursing schools) • Do Oprah’s book club on a diabetes book so that millions of women read it and realize the importance of visits (do a community diabetes book club, have an influential community member campaign for diabetes health)

35. Patients not coming in for recommended diabetes visits: What would a 5 year old do? • Call his friend’s mom to see why he wasn’t coming over • Get some new toys so his friend would come play • Throw a party • Be extra nice • Have hold his friend’s hand on the way over

36. Patients not coming in for recommended diabetes visits: What would a 5 year old do? • Call his friend’s mom to see why he wasn’t coming over (call patients) • Get some new toys so his friend would come play (add an attraction that will draw people to your facility) • Throw a party (hold a special event with a give-away) • Be extra nice • Have hold his friend’s hand on the way over (facilitate the formation of community buddies)

37. Patients not coming in for recommended diabetes visits: What would a pro football player do? • Get the whole team to help • Take the patient to “training camp” • Assign a special coach to the patient • Hire a trainer to motivate the patient • Waffle over whether or not you will have diabetes this year or if you will stay glucose intolerant for another year.

38. Patients not coming in for recommended diabetes visits: What would a pro football player do? • Get the whole team to help (partner with others like nurse educators, etc to contact and intervene with the patient) • Take the patient to “training camp” (take full advantage of those times when the patient does come in-arrange doc, dietician, education in one day) • Assign a special coach to the patient (case management) • Hire a trainer to motivate the patient (in home visits from a support group member)

39. One PDSA (Plan Do Study Act) Tool I Like • Can serve as “minutes” for rapid PDSA cycles that occur with hallway huddles as opposed to real meetings • Mini-project plan

40. http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Plan-Do-Study-Act+%28PDSA%29+Worksheet.htmhttp://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Plan-Do-Study-Act+%28PDSA%29+Worksheet.htm Available if you have an IHI login and is Free

41. Matrices • Keep you organized • Visual, dashboard type way to communicate status of interventions

44. Questions/Comments?