This definition leads to more than implementation of Lean tools in a hospital setting but also addressing culture, change management and moral.

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1 The lean structured improvement activity approach is new to Orlando Health. The Operational Effectiveness Department is leading the development and facilitation of Structured Improvement Activities (or Kaizen). We have developed a working definition of Lean for the hospital: 1. Continuous Improvement 2. Respect for people This definition leads to more than implementation of Lean tools in a hospital setting but also addressing culture, change management and moral. 1

2 One of the first departments of the hospital to engage in a Structured Improvement Activity was the Orlando Health Rehabilitation Institute (OHRI). The Orlando Health Rehabilitation Institute is a 30+ year program and the only CARF accredited Spinal Cord Program in Central Florida. They are in the top 10% of customer service and regularly produce excellent outcomes for patients. 2

3 The admission process was littered with waste leading to underutilization of the program. Due to the waste in the process, Orlando Health was forced to send patients to other postacute care centers and executives were questioning the plan for a second floor in a new building currently under construction. Upon investigation, the operational effectiveness team learned of two themes for the inability to bring patients into the rehabilitation institute. The first problem related to process and data. (Numbers) ---The average monthly census was 58% of the expected monthly census. ---Initial data collection showed excessively long response times around admission decisions The second theme discovered in pre-work for the team related to employee dynamics both internally and externally to the Rehabilitation Institute. (Collaboration) ---Lack of clear understanding of roles ---Breakdowns in communication ---Lack of daily efficiency expectations internally and externally ---Inability to trust decisions ---Learned helplessness 3

4 Unit Bed Capacity: 42 Realistic Capacity Target: 40 (less by two to accommodate issues such as isolation patients) Thehospital Chief Operations Officer also validated this number through analysis of admissions that would qualify for inpatient rehabilitation services. For patients, this means 50 patients who qualified for rehabilitation services were turned away, likely to receive suboptimal care for their needed level of care. 4

5 A Structured Improvement Activity (SIA) was planned with a specific charter for a team of people. Team: 2 Facilitators 2 Process Owners 7 Team Members The team was tasked with increasing the quantity of admissions by improving access to the rehabilitation unit through decreasing variation and increasing efficiency of the admission process. The team spent approximately 35 hours in 5 days working through a specific set of tasks facilitated by the Operational Effectiveness department. Day 1: Current State Observations Day 2: Current State Mapping / Problem Identification Day 3: Root Cause Analysis and Gemba Board Generation Day 4: Future State Mapping / Implementation Planning Day 5: Review of Specific sub process / Action Item Implementation 5

6 Customer: Beforethe team was released to go to the gemba, a short lesson on waste and customer focus was provided. The patient is the ultimate customer of theadmission process but there are other customers along the way. The admission team, physicians and care coordinators work together providing different pieces of information during the process. Each of these groups of people are the customer at some point. Gemba Work: (Gemba = where the work takes place ) The team s first action was to shadow the admission team members with the intent to understand the process and learn to see waste. The most painful waste discussed during the observations was a lack of communication between care coordinators and the admission team. This was determinedto be a root cause for much of the observations in the gemba. 6

7 The pick chart method was used to prioritize problems identified in the gemba. Possible: 1. A solution can be implemented within 45 days 2. Thesolution provides a low level of impact to the situation Implement: 1. A solution can be implemented within 45 days 2. Thesolution provides a high level of impact to the situation Challenge: 1. A solution cannot be implemented within 45 days 2. Thesolution provides a high level of impact to the situation Kill: 1. A solution cannot be implemented within 45 days 2. Thesolution provides a low level of impact to the situation 7

8 During the event the team reduced hand-offs in the process by 30% by standardizing the process for each patient admission. They created expectations for physician communication with the admission team and patients to assure the appropriate information was relayed at the correct time. A couple of the team Just Do Its were to change an office layout and update a form; both reducing waste. The team determined the best methods to track performance to the admission process was to have biweekly gembaboard huddles. 8

9 A GembaBoard Huddle meeting was instituted to improve sustainability of process improvements and drive further actions. The GembaBoard Huddles is where the solution for the first problem of numbers and data meets the solution to the second problem of employee dynamics and communication. It addresses several issues around breakdown of communication, related metrics and adherence to process standard work. Everyone who affects the admission process is invited to the GembaBoard Huddle, thus improving communication with all customers; patient and internally. The GembaBoard is largely a hand drawn metric board. Data is gathered and recorded in real time instead of waiting for computer inputs or a software system to generate. Lack of technology allows for flexibility in data gathering. Sections of the Gemba Board: 1. Daily Census 2. Reasons the daily census did not meet the target 3. Communication metric around time from referral to response given to care coordination of patient approval 4. Turnover metric measuring the point a discharge order is written from the previous unit to the point a bed is assigned in the rehab unit 5. Time of patient discharge from the rehab unit with reasons why if there is a late discharge 6. Time of patient arrival to the rehab unit 7. Current actions for the huddle team 9

10 Throughput metric: Red line / Dots: Discharge information The targeted discharge time for patients leaving the rehabilitation facility is noon. Any red dot above this line is a miss. Black line / Dots: Admission information The targeted admission time for patients leaving the rehabilitation facility is 1pm. Any black dot above this line is a miss. The team came up with this metric to assess the turnover and throughput of the area. They wanted to make sure patients were leaving the facility before new patients were arriving. They had a goal of patient arrival by 1pm to allow for shortened length of stay and a better transition for the patient. 10

11 Largest issues for late discharges in the day: 1. Family was delayed in picking up the patient 2. Patient needed to be unexpectedly discharged to a higher level of care 11

12 This metric measuresthe time from the hospital care coordinator generating a referral to the rehab institute to the admission team providing a response to the care coordinator of the patient acceptability for the unit. Improvement of this metric has improved communication and reputation of the admission team by providing a timely response to the internal customer. It also allows care coordination to work with the patient sooner in preparation of their next step in their rehabilitation. As a result, the patient receives better options and clear communication. The StructuredImprovement Activity officially ended in April, where there had already been considerable improvement. The team continued to work several items after the structured improvement activity to reach full implementation. A three month check back, in July, showed continued improvement of metrics within control of the admission staff. 12

13 This metric measuresthe time from a discharge order written in the hospital to the assignment of a rehab bed for the incoming patient. Improvement of this metric decreases waiting for the patient, hospital unit staff and rehab unit staff. The rehab unit is now assigning beds before a hospital discharge the majority of the time; staying a bed ahead. 13

14 One of the metrics had steady improvement then took a sharp decline. The average monthly census reached a 32% improvement then fell almost to the original census level. While the group is not currently meeting this target, it has brought to light some more of the issues related to employee dynamics and communication. The cause of the downturn of this metric is outside of the area of control for the admission staff but has been appropriately escalated to the senior leadership team in the hospital. This is a benefit of the project. During the time the process was followed and adequate resources were available, the census improved. The cause for the sharp drop in volume was due to a staffing issue the admission team cannot affect. Without regular review of these metrics and discussion around the issues, the leadership team would not have been aware of the severity or causes of this issue. Implementation of the GembaBoard Huddles created sustainability for process improvements with the admission department employees at the Orlando Health Rehabilitation Institute. 14

15 Another result of the Structured Improvement Activity, beyond metrics, was a visible increase in empowerment of the admission department employees. The staff had previously operated from a standpoint of helplessness and defeat. They had experienced considerable change and frustration from team dynamics. A few quotations from the team and other staff members illustrate the change in attitude. 15

16 As the Operational Effectiveness department continues to facilitate structured improvement activities at Orlando Health, there is a lesson to be learned about the inability to sustain the volume metric. While the team was well supported from the administration through regular communication during the event, other stakeholders need to have the same involvement and communication to assure the culture of a department will support changes and new processes in the area. 16

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