tollgate int med cycle time 151120

CPIMS # DON 020401 1

Naval Hospital JacksonvilleCAPT Troy Borema, Project Champion

LCDR Eugene Smith Jr MSC USN, Lead Belt/Process OwnerMs. Carola Miner, Command Black Belt

Mr. Robert Doyle, NME Black Belt Mentor

Internal Medicine Encounter Cycle Time


NME-Naval Hospital Jacksonville-FY15: Internal Medicine Encounter Cycle Time

Core TeamProject Lead Project Sponsor /

Champion Command Black Belt Financial SME

LCDR Eugene Smith Jr. MSC USN

CAPT Troy Borema MC USN

Ms. Carola Miner Ms. Wanda Bartley

Team Members

AWO1 Adam Reed USN(GB Co-Lead)

AWO1 Eric Leide USN(GB Co-Lead)

Ms. Carla Little RN(Int Med Clinic Nurse)

Ms. Ann Mott FNP(Int Med Clinic PCM)

LT Steven Koplin MC USN(Int Med Clinic PCM)

HN Kyle Bowen USN(Int Med Clinic Corpsman)

HN James Messersmith USN (Int Med Clinic Corpsman)

HN Yolanda Romero USN(Int Med Clinic Corpsman)

HN Jacob Moulton USN(Int Med Clinic Corpsman)

3

Project CharterProblem Statement: Project Goal:Concern that the current patient demand at Naval Hospital Jacksonville Internal Medicine Clinic may exceed the capacity of Internal Medicine providers was identified during Leadership Rounds in March-April 2015. During FY15, through 31MAR15, the existing processes in the Internal Medicine Clinic have resulted in a three day appointment completion rate of 79%, as well as removal of providers from the appointment schedule to complete encounters and provider job dissatisfaction.

• Create a streamlined process that reduces patient cycle time and improves the capacity of the Internal Medicine Clinic to meet patient demand

• Increase the percentage of Internal Medicine Clinic encounters meeting the Department of Defense Three Day Completion Standard

Expected Benefits: Metric Baseline Improvement Goal

Improve capacity of Internal Medicine Clinic to meet patient demandIncrease the percentage of internal medicine encounters meeting the DoD Three Day Completion StandardReduction in provider dissatisfaction

3 Day Encounter Completion

79%Jan-Mar 2015 95%

Mean Patient Flow Cycle Times

Support Staff-PatientProvider-Patient

33 Minutes29 Minutes

20 Minutes20 Minutes

Mean Cycle TimeEncounter Completion

3.27 DaysApril 2015 Less than 3 Days

TollgatePlanned End

DateActual End

DatePrimary Metric:

Three Day Encounter Completion from monthly DoD DQMC program audit.Pre-Event 29MAY15 19MAY15

Event 26JUN15 09SEP15

Post-Event 17JUL15 12NOV15 Secondary Metrics:

Cycle Time: Patient Flow: Patient Check-In to Corpsman Provider TurnoverCycle Time: Patient Flow: Provider Review Patient Info o Proceed to Next PatientCycle Time: Patient Check-In to Encounter signed in AHLTA

Validate 31JUL15 30NOV15


Voice of the Customer• Patients:

• Patients have to wait past scheduled appointment time when encounter cycle times extend beyond scheduled appointment durations.

• Support Staff:• Unique provider preferences for patient appointments can lead to support staff having

to scramble to get patient into rooms

• Providers:• Providers staying late and needing time out of clinic to complete patient encounters

negatively impacting access to care for some patients.

• Command Leadership: • During leadership rounds Internal Medicine Clinic providers expressed concern that

patient enrollment level may be greater than provider’s capacity to deliver care. • DHA:

• Internal Medicine Clinic consistently below DoD standard for timely completion of encounters.


Communication Plan COMMUNICATION PLAN: Internal Medicine Encounter Cycle Time

Purpose Audience Media Discussion Topics Responsible Person

Frequency of Communication

Location Notes/Status

MEETING AGENDA Project Team

Email Project status Next team meeting

(date, time, location, etc.)

Action item status Other project info

Team Leader

Q Meeting Outlook

CHAMPION MEETING

Champion/GB/BB/ Sponsor/Process Owner

Face-to Face

Project Charter Brief Tollgate Briefs Project status

Team Leader w Lead Belt

Within 2 weeks of completing Tollgate

Varies

TEAM MEETING Project Team Face-to Face

Charter, SIPOC, Current State Map, Ishikawa, VOC, VSA & VSM, etc

Project Leader

As needed. Agenda can include problem solving, evaluation, reporting, decision making, or planning

Varries

PROBLEM SOLVING MEETING

Project Team and Ad Hoc/SMEs as needed

Face to Face Analysis of specific issue using appropriate tools.

Team Leader w Lead Belt

As needed, may be included in regular team meeting

Varies

EVALUATION MEETING

Project Team Face-to Face

Project Status Review of barriers to

implementation

Team Leader

Monthly or as needed, may be included in regular team meeting

Varies

REPORTING MEETINGS

Project Team Email Team progress and updates of outcome or in-process metrics

Lead Belt Monthly or as needed. may be included in regular team meeting

Varies

DECISION MAKING MEETINGS


Face-to Face

Proposed Charter changes and actions on JDIs

Team Leader

As Needed, may be included in regular team meeting

Varies

PLANNING MEETING


Face-to Face

Plan JDI implementations

Project Team

As Needed, may be included in regular team meeting

Varies

6

Data Collection Plan

CPIMS # DON 020401

NH Jacksonville: Internal Med Cycle Time What questions do you want to answer?

1.Is IntMed Clinic meeting DoD requirement for timely completion of patient encounters. 2. How efficient is the patient flow process in Internal Medicine

Metric Data Type (Discrete /

Continuous)

Operational Definition

Sampling Notes

Source and Location

Collection method Who will collect data

Three Day Encounter

Completion Discrete

Per DoD Data Quality Management Control

(DQMC) SOP 100% Sample Monthly DQMC Report Obtain from NH Jax Data Quality Manager Ms. Wanda Bartley

Cycle Time: Encounter

Completion Continuous

Time from Patient Check-In to Provider signs AHLTA Record

100% Sample CHCS Ad Hoc “BOCI”

Spool and save report as text file. Import into Excel and calculate the difference between Patient Check-In and Provider signature on

AHLTA encounter.

Health Systems Specialist, Tricare Operations Dept.

Cycle Time for Provider and Support

Staff Continious

Time from Patient Check-In to Corpsman

Provider Turnover

Time from Provider Review Patient Info o

Proceed to Next Patient

Minimum of 5 patient

encounters for each of 2 providers

Internal Medicine Patient Schedule Time study checklist AWO1 Adam Reed

How will data be used? How will data be displayed?

What is plan for starting data collection?

To assess baseline performance and quantify improvements. Cycle time for Provider and Support Staff: Bar Chart Three Day Encounter Completion: Run Chart Cycle Time Encounter Completion: Control Chart

Obtain baseline data from DQ Manager Ms.Bartley. Create tracking tool for capturing Provider and Support Staff Cycle Times. Create CHCS ad hoc for encounter completion cycle time.

7

Baseline Data

CPIMS # DON 020401

Metric Baseline Goal Delta

Previous Support Staff Cycle Time 33 minutes 20 minutes 13 minutes

Previous Provider Cycle Time 29 Minutes 20 minutes 6 Minutes

Encounter Completion Cycle TimePt Check-In to AHLTA Signature 3.19 Days <3 Days 0.19 Days

Three Business Day Encounter CompletionDoD Data Quality Standard

79%Sigma 2.19

95%Sigma 3.14

16%0.95

CPIMS # DON 020401

SIPOC

8

CustomersSuppliers Process

•Beneficiaries•IMD•Command Leadership•DON/BUMED

•Time to document care•Support Staff

•Training•# staff on duty

• Appts available•AHLTA -CHCS•# of enrollees•ATC regulations and standards•PCM availability•Check-in process and forms

•Patient Encounter Complete•Patient Health•Reported Workload•HEDIS Compliance•Patient Satisfaction•Ancillary Services• Scripts• Lab • X-Rays ect…• CHCS data• Access to care and other

PCMH reports•Access to Care•ICE Comments

CTQCTP

Support Staff Calls Patient

Provider Examines

PatientProvider

Documents Care

Inbound: Patient Checks-In

for Appt

•Patients•PCMs/Providers•Clinic/command leadership•DON, BUMED

Inputs Outputs

Outbound: Encounter reported complete in CHCS Ambulatory Data Module

2 - 1440 Minutes

VOC

Limited time to complete encounter

documentation requirements

9

Current State Value Stream Analysis

• GEMBA walk of patient flow included time study to measure corpsman and provider processes

• Support staff cycle time started with patient documentation pocked up by support staff• Provider cycle time started with provider reviews patient information. • Providers are frequently unable to close out patient encounters (AHLTA note signed) until

after patient leaves due to next waiting patient, or need for additional info/labs/ect...• Visio Version of process maps included as documents in CPIMS

START: PATIENT CHECKS-IN FOR APPOINTMENT

PATIENT ARRIVES AT FRONT DESK

FRONT DESK SCANS ID AND CHECKS

PATIENT IN

FRONT DESK QA PAPERWORK

FRONT DESK MOVES

PAPERWORK TO INBOX

SUPPORT STAFF CHECK ROOM AVAILABILITY

CURRENTINSURANCE

PAPERWORK

CURRENTINSURANCE

PAPERWORK

FRONT DESK GIVE PATIENT DD 2569

TO COMPLETE

FRONT DESK PRINTS SF600 AND STITCH

& TIME

FRONT DESK PRINTS PLAN OF ACTION

FORMS

FRONT DESK PRINTS PAP FORMS

SUPPORT STAFF PREPS &

SANITIZE EXAM ROOM

PATIENT DOCUMENTATION

PICKED UP BY SUPPORT STAFF

SUPPORT STAFF CALLS

PATIENT

PATIENT IS MOVED TRIAGE ROOM

SUPPORT STAFF TAKES WEIGHT,

VITALS, AND BLOOD PRESSURE

DATA INPUT INTO COMPUTER

SUPPORT STAFF INITIAL HPI ON

SF600

SUPPORT STAFF TABS IN TSWF INFORMATION

SUPPORT STAFF TRIAGE

ISSUESPAP

FEMALE STANDBY

REQUESTED

FIND FEMALE STANDBY

ROOM AVAILABE

ROOM OCCUPIED

WAIT FOR AVAILABLE ROOM

PREP PATIENT ROOM

MOVE PATIENT TO EXAM ROOM

SUPPORT STAFF TURNOVER WITH

PROVIDER

PROVIDER REVIEWS PAITIENT

INFORMATION

PROVIDER NEEDS

ADDITIONAL INFO

PROVIDER PULLS ADDITIONAL INFO

FROM PATIENT CHART /

ELECTRONIC MEDICAL RECORD

PROCEED TO EXAM ROOM

NO

COMPLETE PATIENT IDENTIFIERS PROVIDER Q&A PROVIDER

EXAMINES PATIENT

DIAGNOSE AND PRESCRIBE

RECOMMENDATIONPAP

SUPPORT STAFF PLACES LABELS ON SPECIMENS

SUPPORT STAFF DROP OFF

SPECIMEN FOR LAB PICKUP

NEXT PATIENT CHECKED IN

INPUT LABS, MEDICATIONS,

CONSULTS, NOTES, ETC...

WORK ON INCOMPLETE NOTES

ECT… UNTIL NEXT PATENT ARRIVES

INPUT LABS & MEDICATIONS AND WORK ON

NOTE

PROCEED TO NEXT PATIENT

END: ENCOUNTER REPORTED AS COMPLETE IN CHCS AMBULATORY DATA

MODULE (ADM)

CHECK IN SHEET

AVAILABLE

YES

PATIENT COMPLETES

SHEET

SUPPORT STAFF PRINTS

FORMS

FIND SCALE TO WEIGH

PATIENTMEDICATION

REVIEW

REVIEW LAST NOTE & LAB

DISCUSSES PRIOR TREATMENT

EFFECTIVENESS

PROVIDES RECOMMENDATIONS

DISCUSSES CHIEF

COMPLAINT

CHECK OUT SHEET

AVAILABLE

RETRIEVE SHEET FROM

OFFICE

PATIENT COMPLETES

FORM

YES

NO

YES

NO

YES

YES

NO YES

NO

NO

YES

NO

NO

YES

NO

YES

YES

NO

Start Support

Staff Cycle Time

End Support

Staff Cycle Time

Avg Support

Staff Cycle Time

33 Min

Start Provider

Cycle Time

EndProvider

Cycle Time

Avg Cycle Time Pt Check-In to

Completed Encounter:3.19 Days

DOCUMENTATON COMPLETE

YES

NO

PRE PRINTED LABELS AVAIL?

PRINT LABELS

NO

YES

PROV UNIQUE REQUIREMENT

NO

Avg Provider

Cycle Time 29 Min

Handoff Corpsman to Provider


10

RCA: Affinity Brainstorming with Multi Voting & 5 Whys

Affinity Question: What delays patient flow and completion of encounter documentation

Consensus Prioritization 2 1 3

Affinity Header Variation in Patient Flow Not Enough Time Appt Scrubbing/Prep

Affinity Cards

No consistent use of exam rooms.

Room not cleaned after patient leaves Lots of paperwork Enrollment panels too high Not sure what patient needs at check-in

(HEDIS, TPC, ect…)

Different providers use different forms.

Patient did not complete forms. Too much paperwork Too many patients Not knowing time expectations for encounters.

Patients don’t always go to the same exam room Appt go over time. Complicated Patients Appt times not long enough to

complete notesEquipment needed for patient not always

ready.

Forms not always available Lots of paperwork Having to look for additional

information Not enough time in appt to complete note. Scrambling to find a standby

Equipment needed for patient not always ready.

Patients don’t know what to do with forms they fill out. Waiting for labs or other info. Patients have more than 20 minutes of

problems. Not knowing why a patient is coming in.

New corpsman don’t always know what to do. Staff Turnover Need additional information to

complete Assessment/Dx/Plan Unrelated follow on questions Having to look for additional information

Clinic Orientation for new corpsmen varies.

Having to look for additional information

Not sure what patient needs at check-in (HEDIS, TPC,

ect…)Room not ready, previous patient is

still in the room.

Different providers use different forms.

11

Implementation Plan

CPIMS # DON021765

Date Implementation ActionRCA Link

Start Finish Responsible Party

Team Agreement

Process Owner Understanding

Comments/Outcome

Apr 2015

Optimize utilization of Support Staff with Standard Work SOP(Variation in Patient Flow)

1May15 31Aug 15 Int Med LPO Yes YesClarified, standardized and simplified process steps to get patient ready for provider. Created written SOP for support staff process.

Apr 2015Reestablish Team Huddles(Appt Scrubbing/Prep)

1May15 31Aug15 Int Med Team Leads Yes Yes

Reestablished daily team huddles which enable identification of patients prep requirements and help to reduces last minute scrambling for information, supplies and equipment that prolong cycle times for support staff and provider processes

Apr 2015Provider Admin Time

(Medical Documentation Requirements)

1May15 31Aug15Champion and Int Med Dept

HeadYes Yes

Increased patient demand and complexity/variation of patient health issues limit amount of time available to complete all required medical documentation within scheduled appointment times. Champion approved 3 hours of uninterrupted, rotating administrative time per week for providers to complete medical documentation.

12

Process Artifacts

SOP for Internal Medicine Support Staff SOP for CHCS Ad Hoc BOCI

13

Future State Value Stream Analysis

• Support staff process streamlined from 27 to 16 steps. New process includes Standard Work SOP for Support Staff and decreased average cycle time by 19 minutes, from 33 to 16 minutes (↓57.6%).

• Provider process streamlined from 22 to 16 steps. New process decreased average cycle time by 6 minutes, from 29 to 23 minutes (↓20.7%).

• Visio version of process maps uploaded into CPIMS documents

START: PATIENT CHECKS-IN FOR APPOINTMENT

PATIENT ARRIVES AT FRONT DESK

FRONT DESK SCANS ID AND CHECKS

PATIENT IN

CURRENT INSURANCE

PAPERWORK

FRONT DESK GIVES PATIENT

PAPERWORK TO COMPLETE

FRONT DESK PRINTS NECESSARY FORMS (SF600, STITCH IN

TIME, PLAN OF ACTION, & PAP)

FRONT DESK MOVES PATIENT PAPERWORK TO

INBOX

PATIENT DOCUMENTATION

IS PICKED UP BY SUPPORT STAFF

SUPPORT STAFF CALLS PATIENT

PATIENT IS MOVED TO TRIAGE ROOM

SUPPORT STAFF TAKES PATIENTS WEIGHT, VITALS,

AND BLOOD PRESSURE

DATA IS INPUT INTO ELECTRONIC

MEDICAL RECORD

SUPPORT STAFF INITIALS HPI ON

SF600

SUPPORT STAFF TABS IN TSWF INFORMATION

SUPPORT STAFF COMPLETES SF508

MEDICATION REVIEW

SUPPORT STAFF TRIAGES ISSUES PAP

FEMALE STANDBY

REQUESTED

FIND FEMALE STANDBY

SUPPORT STAFF DOES TURNOVER

WITH PROVIDER

PROVIDER REVIEW PATIENT

INFORMATION

PROVIDER REQUEST

SUPPORT STAFF TO ORDER

REFILLS

SUPPORT STAFF ORDERS

MEDICATION REFILLS

PROVIDER READY TO PROCEED

REVIEW PATIENT CHART /

ELECTRONIC MEDICAL RECORD

PROCEED TO EXAM ROOM

COMPLETE PATIENT

IDENTIFIERSPROVIDER Q&A EXAMINE PATIENT

DIAGNOSE AND PRESCRIBE

RECOMMENDATIONSPAP

SUPPORT STAFF PLACES LABELS ON

SPECIMENS

SUPPORT STAFF DROPS OFF

SPECIMENS FOR LAB PICKUP

NEXT PATIENT CHECKED-IN

INPUT LABS, MEDICATIONS,

CONSULTS, NOTES ETC...

WORK ON INCOMPLETE NOTES

ECT...UNTIL NEXT PATIENT ARRIVES

INPUT LABS AND MEDICATIONS AND

WORK ON NOTE

PROCEED TO NEXT

PATIENT

END: ENCOUNTER REPORTED COMPLETE IN CHCS

AMBULATORY DATA MODULE YES

NO

NO

YES

YES

NO

YES

YES

NO

NO

YES YES

NO

NO

ESTABLISH & PRIORITIZE

PATIENT AND PROVIDER ISSUES

SET ACHIEVABLE GOALS FOR THE

VISIT

Avg Cycle Time for

completed encounter:2.52 Days

DOCUMENTATON COMPLETE

Intervention:Sched Admin Time

Start Support

Staff Cycle Time

End Support

Staff Cycle Time

Avg Support

Staff Cycle Time

14 MinStart

Provider Cycle Time

End Provider

Cycle Time

Avg Provider

Cycle Time 23 Min



Intervention: Standard Work for Corps Staff

Intervention: Revitalize Huddles Allows for improved care coordination and impacts

multiple steps

Intervention: Revitalize Huddles Allows for improved care coordination and impacts

multiple steps

14

Results DataThree Day Encounter Completion

CPIMS # DON 020401

• Standardization of support staff process for getting patient ready for provider and scheduled admin time to complete records increased available time to complete patient encounters.

• Increased 3 Business Day Compliance by 8%:

• from 79% to 87%.• Improved Process Sigma by 0.33:

• From 2.3 to 2.63.• Process significantly improved with

opportunities for continued improvement.

15

Results DataEncounter Completion Cycle Time

• Time from check-in to provider signature in AHLTA for individual encounters decreased from average of 3.19 days in April 2015 to 2.52 days in Oct 2015.

• Upper control limit decreased from 13.7 days to 12.75 days.

• T Test for difference in cycle times significant with P-Value of 0.002 and CI of 95%.

• Data includes all completed encounters for checked in patients between 1-30 Apr and 1-15 Oct 2015.

16

Results DataPatient Flow Cycle Times

• After standardization and simplification of patient flow process, mean cycle times decreased for both the support staff and provider portions of the process

• Support staff cycle time:• ↓ 19 minutes (57.6%).

• Provider cycle time:• ↓ 6 minutes (20.7%)

CPIMS # DON 020401 17

Control Plan

CONTROL PLANProcess Name: NH Jacksonville Internal Medicine Cycle Time

1 2 3 4 5 6 7 8 9 10 11 12

Name of Measure

Measure Definition

Measure Calculation Data Source Goal Measure Frequency

Sample Size

When to Act/Trigger Who Decides to Act

WhoActs

Reaction to Out of Control

Display Method

3 Day coding compliance

Patient Cycle Time Audit

Encounter Complete Cycle Time

% of Kept Encounters closed within 3 Business Days (Definition in DoD DQMC SOP)

Per Data Collection Plan


Monthly average of:# Encounters closed within 3 business days/# of kept encounters.



Data Quality Report

Time Study Checklist


95%

<20Min

Avg < 3 days

Monthly

Monthly

Monthly

100%

Min of 20 patient and 2 providers

100%

When >95% for three consecutive months, or 4 months in a 5 month period.

When mean support staff cycle time is >20 min

When mean cycle time is > 3 minutes

Data Quality Manager

IntMed Clinic LPO

IntMed Dept Head

IntMed Dept Head

IntMed Clinic LPO

IntMed Dept Head

Identify cause of failure and design intervention to correct failure.



Run chart

Run Chart

Run Chart

CPIMS # DON 020401 18

LSS Scorecard

LSS SCORECARD

Metric Name: BASELINE RESULTS

POST INTERVENTION RESULTS

TOTAL CHANGE FROM BASELINE

Patient Flow Cycle Time:(a) Support Staff

(b) Provider(a) 33 Min (b) 29 Min

(a) 14 Min(b) 23 Min

(a) ↓ 19 Min (57.6%)(b) ↓ 6 Min (20.7%)

Encounter Completion Cycle Time 3.19 Days 2.52 Days ↓0.67 Days (21.0%)

3 Day Encounter Completion:(a) Percent Complete

(b) Sigma(a) 79%(b) 2.30

(a) 87%(b) 2.63

(a) ↑0.67 Days(b) ↑0.33 Sigma