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TRANSCRIPT
The Lean Hospital:What does it mean?
Kristin Furfari, MD
Outline
• Waste in the US Health Care System
• Lean principles: The Toyota Method
• Application to hospital medicine
• Discharge throughput: A UH example
Disclaimers
.$4,887
$3,322
$2,808 $2,792$2,561
$2,131 $1,992
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
Unite
d St
ates
Switz
erlan
d
Germ
any
Cana
da
Fran
ce
Japa
n Un
ited
Kingd
om
Per Capita Health Care Spending (US$PPP)
Source: Organization for Economic Cooperation and Development, OECD Health Data 2002
National Health Expenditures (in billions)
$200
$400
$600
$800
$1,000
$1,200
$1,400
$1,600
$1,800
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Inflation-adjusted (1)
Source: Centers for Medicare & Medicaid Services, Office of the Actuary(1)Expressed in 1980 dollars; adjusted using the overall Consumer Price Index for Urban Consumers
10.9%
13.4% 13.2%14.9% 15.4% 16.0%
18.7%
13.1%
0%
2%
4%
6%
8%
10%12%
14%
16%
18%
20%
1988 1993 1996 1998 2002 2004* 2006* 2014*
*ProjectedSource: Heffler et al., “Health Spending Projections for 2004–2014,” Health Affairs (February23, 2005).
National Health Care Expenditures as a Percent
of GDP
Institute of Medicine Report on Medical Errors
50,000-100,000 deaths annually
950,000 patients injured annually
$15 billion-$30 billion in cost
Wasted Time for Hospitalists
Percentage Breakdown of Time
Direct PatientCareIndirect PatientCareProfessionalDevelopmentEducation
Travel
Personal
Indirect PatientCare 69%
Direct PatientCare18%
Waste in healthcare
“The national numbers for waste in healthcare are between 30% and 40% but the reality of what we’ve observed by minute-to-minute observation over the last three years is closer to 60%....It’s everywhere: patient care and non-patient care alike.”
The Problem
• Too little efficiency
• Too much waste
Toyota Production System
• Largest manufacturer in the world• Eight times more profitable than the
industry average• Produced 40% of the “most reliable” car
models on the market in the last decade
Toyota Production System
• Taiichi Ohno: Father of the TPS• Developed his ideas from observing:
The Indianapolis 500The River Rouge plantAmerican supermarkets
Toyota in Healthcare
• Creating an environment of stability
• Elimination of waste
• Rapid identification and correction of errors
What is Lean Thinking?
• A methodology to produce the highestquality product in the shortest amountof time, at the lowest possible cost by eliminating the “seven wastes.”
• Fosters a culture which encourages all employees to continually look for improvement
The “Seven Wastes”
• Waste of Overproduction• Waste of Time (waiting)• Waste of Product Transport• Waste in Excess Processing• Waste in Inventory• Waste in Movement• Waste in Producing Defects
The “Seven Wastes”
• Waste of overproductionSeparate intern, resident, attending, social
services rounding cyclesEntering repetitive information on multiple
documents or forms
• Waste of time on hand (waiting)Primary team waiting for support servicesPatients waiting to make followup
appointmentDelays for bed assignments
• Waste of processingMultiple computer programs to document
patient care informationOrdering more diagnostic tests than the
diagnosis warrantsRetesting
• Waste of stock on hand (inventory)Duplicate medications and supplies in
excess of normal usageUnnecessary instruments in operating room
kitsObsolete charts, files, equipment, paperwork
• Waste in transportationPrimary team traveling to different floors to
see patientsWaiting for transportation to arrive to take
patient to testing, surgery, discharge
• Waste of movementNurses leaving patient rooms for common
suppliesSearching for charts, patients, medications
• Waste of producing defectsIatrogenic illnessMedication errors
Understanding Value
• Understand value as defined by our customersPatients, families, payers, regulatorsPhysicians, nurses, hospitals
High-quality, safe, efficient, appropriate
Understanding Value: Lowry Clinic
• Check in at front desk• Wait in waiting room• Walk with nurse to
assessment room• Nurse takes vitals• Walk to exam room• Wait for physician• Physician exam
• Wait for physician to return
• Physician consult and treat
• Wait for nurse follow-up• Walk to laboratory
waiting room• Wait for labs• Get labs drawn• Check out
Toyota Production SystemUniversity of Colorado Hospital - As-is Credit Process Map
Payment postedto account
Is there acredit
balance?
Is the balanceover $1,000? END
No
Yes Print screen Give to creditanalyst
Credit analystwaits for EOB
Run weeklycredit balance
report(on Monday)
Download toexcel
Manipulate excelbased on criteria(if 2 adj - reverseif 2 pmts - refund
etc.)
Refundappropriate?
Process reverseadjustment
Research (*)
Yes
No
No
Complete excelform
(1 form perrefund)
Print excel formBatch with EOB
<$50K peraccount?
Yes
Create batch inHPA
(group of 25)Post transactions Print batch
header
Bundle up EOBs,batch header,
excel formDeliver to A/P
Yes
Paym
ent p
ostin
gR
efun
d C
lerk
A/P
25 refunds?Supervisor sign-off
Billing OfficeManager sign-off
No Yes
Write vendor# onexcel form, key
visit, $, date, G/Linto Lawson
Add vendor (insco) or temp#
(patient) on thefly
Vendor insystem?
Does batchbalance?
Audit batch / fix Release batch forprinting
Checks printed(next day)
Copy of 2nd copyof check made
for Billing Office
Man
agem
ent
Audit checks vs.paperwork
Scan checks andpaperwork
Checksdistributed
No
Yes Yes
No
- Non Value
- Value Add- Value Enabling
Toyota Production SystemUniversity of Colorado Hospital - To-Be Credit Process Map
Payment postedto account END
Run weeklycredit balance
report(on Monday)
Download toexcel
Refundappropriate?
Research (*)
No
Paym
ent p
ostin
gR
efun
d C
lerk
A/P
Write vendor# onexcel form, key
visit, $, date, G/Linto Lawson
Add vendor (insco) or temp#
(patient) on thefly
Vendor insystem?
Does batchbalance?
Audit batch / fix Release batch forprinting
Checks printed(next day)
Copy of 2nd copyof check made
for Billing Office
Man
agem
ent
Checksdistributed
No
Yes Yes
No
Research (*)
Billing OfficeManager sign-off
Billing OfficeManager sign-off
Billing OfficeManager sign-off
Refundappropriate?
NO
Billing OfficeManager sign-off Research (*)YES Download to
excelDownload to
excel
Download toexcel
- Non Value
- Value Add- Value Enabling
Process Improvement
Preparation
Current state
Future state
Implementation plan
Kaizen
Kai: “Take Apart”
Zen: “Make Good”
The Lean WeekPre-Lean
FriThursWedTuesMonLearn tools
Develop solutions
Go-live
Lean Week
Identify, map and measure current process
Monitor, measure, control, closePost-Lean
Standardization
• Standardization is the basis for continuous improvement and quality– Repeatable, stable methods provide a
predictable, regular output– Creates a safe culture to point out
problems and a standard way to fix them
Standard Work
• The technique of achieving consistent performance by creating a consistently applied method of doing a task
• The creation of the method by the people doing the work
• Should lead to continual improvement
Standardization
“Today’s standardization…is the necessary foundation on which tomorrow’s improvements will be based. If you think of standardization as the best you know today but which is to be improved on tomorrow—you get somewhere. But if you think of standards as confining, then progress stops.”
Henry Ford, 1921
Virginia Mason Medical Center
• Ventilator-associated pneumonia
0
5
10
15
20
25
30
35
2002 20004
CasesDeaths
Pittsburgh Regional Healthcare Initiative
30
60
90
120
150
Central Line-AssociatedBloodstreamInfections
2001 2002 2003 2004
University of Michigan
• PICC lines placed within 24 hours of request:– Initially: 50%-70%– After Lean: 90%-95%
Overall 36% decrease in average time to placement
12 West Lean Outcome DataOctober 2008-April 2009
22%
44% 42%29%
50% 54%
72%84%
0%10%20%30%40%50%60%70%80%90%
100%
Baseline Oct Nov Dec Jan Feb Mar April
Percentage of Discharges by 2pm
Opportunities• Identify and reduce waste in the 7E discharge
process
• Identify hospital system throughput delays
• Recommend process improvements for hospital-wide discharge process barriers
• Understand how efficiency of the discharge process affects patient satisfaction
Goals• Reduced time from room empty to room occupied
• Double the percentage “clean to occupied bed time”in less than 60 minutes from 22% to 44%
• Improve daily median discharge time by 1 hour for Monday through Friday discharges
• Create a control plan to monitor and sustain improvements
Baseline DataMedian Discharge Time by Day of Week:
10/1/09-12/31-09
1200
1300
1400
1500
1600
M o nday T uesday Wednesday T hursday F riday
Median Time ofDischarge
Baseline DataClean to Occupied Bed Time:
10/1/09 – 12/31/09
Pha
rmac
ist
EV
SA
ttend
ing
Phy
sici
anP
rimar
y R
NTr
ansp
orte
rH
ome
Hea
lth C
oord
inat
orP
atie
nt S
ervi
ce C
oord
inat
orC
harg
e N
urse
Cas
e M
anag
erS
ocia
l Wor
ker
DC IV DC Home orders are
w ritten(note 1)
Put chart on rack
(note 2)Flag the chart
yellow
Put chart on desk
(note 3)
Stop
Notified of DC order
(note 4)
Discuss DC Plan w ith Patient(note 6)
Complete nursing tasks
(note 7)
Print instructions f rom MicroMedex
Take instructions to patient room
(note 8)
Complete patient
education(note 9)
Remove IV access Prescript
ion filled at UCH?
Give prescription
to patient
Tube prescription
to Atrium Pharmacy
No
YesNeed
transportto car
Let patient w alk to the
car
No
Order Transport
Stop
Yes Complete Charting
Remove patient from
Care M anager(Note 10)
Tell Charge RN patient has been
discharged
Ask C.N.A. to remove equipment f rom room
Hear sound of chart being put
in rack
Review DC order and
prescriptions
Page other disciplines to complete pt care w ith
priority for DC
Enter OBS charges in to
IDX
Write DC on large w hite
board
Call RN to let him/her know
about DC order
Highlight patient's room
number on assignment
sheet
Put confirmed DC in
Bedboard
Transcribe DC order into Care
Manager(note 11)
Place chart back on rack for RN to co-
sign
Record DC info in Census
Book(note 14)
Write DC in Medical
Records log(note 15)
File DC paperw ork
copy
Breakdow n chart
Photo copy DC paperw ork
Page other disciplines to complete pt care w ith
priority for DC
Notify Primary RN about DC
orders
Remove patient f rom
Care Manager(Note 10)
Assist Primary RN w ith DC if RN is too busy
Go to patient's room
Reschedule pt pick up in system
Receive page from Care
M anager that pt is ready for discharge
Take patient off unit
Take pt to car Enter job completed in
phone system
Will pt be ready in 5
mins
Does pt need to go
to pharmacy
Is wait at pharmacy less than 5
minutes
Reschedule pt pick up in system
Take patient to pharmacy
YesYes
Yes
No
No
No
Does pt need home health care
Stop
Review DC paperw ork (pink sheet) for medical
needs
Complete "home care
assessment"(Note 12)
Contact home care agencies
Compile paperw ork to
send to accepting agency
Send paperw ork to
agency Stop(16)
No
Yes
Does pt need home antibiotics
Stop
Review DC paperw ork (pink sheet) for medical
needs
Fax pink sheet to infusion
center
Call company to set up equipment delivery(note 13)
Stop(17)
No
YesDoes pt
need home equipment
No
Yes
Stop
Determine payor source
Get chart f rom rack
Talk to family about w hat they w ant
StopDoes pt
need SW services
No
Yes
Does pt need inpt
meds befo re DC
Expedite meds being
processed by inpt pharmacy
Stop
No
Yes
No
YesDoes pt
have prescriptions
to be filled
Counsel patient on use
of certain medications
Log into phone system ("in progress")
Clean room (45-60
mintues)
Receive page w ith room number("dirty")
Go to patient room
Find someone to remove medical supplies
Log out in phone system
("clean")
Notify Nursing
Staff of DC
Orders Complete?Accurate?
(5)
Call Doctor for clarification
Enter complete code in phone
system
Yes
Stop
Can pt affo rd prescriptions
Yes
Will patient qualify fo r
CICP
Notify Social Worker for assistance w ith CICP
registration
No
Yes
Does pt qualify fo r outpt
assistance program
Refer pt to outpt
pharmacy for assistance
Contact physician to recommend
cheaper therapy
No
Yes
No
Yes
No
Copy chartContact SNF about
placement
Arrange transportation
Call SNF to update about
departure time/needs
Fax orders to SNF
Phase II• Compare staff interview and observation process
maps
• Meet with 7E staff to identify wastes in the process and determine Kaizen events
• Implement solutions
• Monitor data compared to baseline/goals
• Create plan for sustainability of project
References
• Berczuk, C. The Lean Hospital. The Hospitalist. 2008; June• Bush, RW. Reducing waste in US Health Care Systems. JAMA. 2007;
297(8): 871-874.• Kim CS, Spahlinger DA, Kin JM, Billi JE. Lean Health Care: What Can
Hospitals Learn from a World-Class Automaker? J Hosp Med. 2006; 1(3): 191-199.
• Liker JK. The Toyota Way: 14 Management Principles from the World’s Greatest Manufacturer. McGraw-Hill: 2004.
• O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006; 1(2): 88-93.
• Spear SJ. Fixing Healthcare from the Inside, Today. Harvard Business Review. 2005; Sept: 1-14.
• Spear SJ, Bowen HK. Decoding the DNA of the Toyota Production System. Harvard Business Review. 1999; Sept: 96-106.
Questions?