Getting Better: Using Lean/Six Sigma to Improve Performance in a Correctional Health Care System Presented by Amy Jo Harzke, Dr. P.H. Kelly Coates, M.B.A. Academic & Health Policy Conference on Correctional Health Houston, TX March 21, 2014
Fiscal Challenges in Prison Health Care Systems Increasing proportion of older inmates Rising health care costs Decreased or static funds
Do More & Better With Less Continuous performance improvement methods & strategies needed to Improve efficiency Reduce waste Improve quality/outcomes Reduce errors
Objectives Introduce Lean/Six Sigma (LSS) methods for continuous performance improvement Discuss the promise and pitfalls of the application of LSS methods in health care settings Describe past applications and their impact within different sectors of Correctional Managed Care in Texas Discuss other in-progress and potential applications of LSS in correctional health care environments
I. Introduction to Lean/Six Sigma (LSS)
What is Lean/Six Sigma? Continuous process improvement/ excellence approach Structured problem-solving framework Fact-based, data-driven decision making methodology Business philosophy Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
Concept of Process All work viewed in terms of processes, sequences of steps that transform inputs into outputs Understanding process inputs, outputs, and their relationships is key for process improvement INPUTS Raw Materials/ Information Procedures PROCESS/ SYSTEM OUTPUTS Products Services Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
Guiding Principle of LSS Identify process inputs with the largest effect on output(s) Determine how to control inputs in order to produce desired output(s) with desired, specified characteristics Improved efficiency Reduced errors/defects Cost minimization or savings Increased profit or market share y = f(x) Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
What is Lean? An integrated sociotechnical system with the main objective of eliminating waste by reducing or minimizing supplier, customer or internal variability Socio-technical suggests need to manage social and technical systems simultaneously Lean methods popularized by Toyota (~1949 ~1975), but had roots in Ford and General Motors Phrase Lean Manufacturing coined in 1990 by James Womack wrote in The Machine that Changed the World Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
Lean Focus: Waste Waste is inherent part of most processes ~80% to 90% of all process steps are nonvalue added The challenge is to identify and reduce or eliminate non-value added process steps Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
What Waste? 8 Common Types of Waste 1 Overproduction 2 Inventory (excess) 3 Defects 4 Processing (over-processing) 5 Waiting 6 Motion 7 Transportation 8 People (underutilization) Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
How is Lean Different? Teamwork Well-informed, cross-trained, decision-making team members Work spaces Clean, organized, & well-marked Flow systems as opposed to batching and queuing Pull systems based on demand, as opposed to push systems which are based on forecasts Reduced lead times through more efficient processing, set-ups, and scheduling Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
Lean: Before & After Current process: Meandering stream with stagnant pools Lean Process: Pipelines with fast & predictable flow Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
Lean Toolbox Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
5S Methodology Japanese English Description Seiri Sort Identify needed items, discard the rest Seiton Set in order Organize needed items to allow for easy & immediate retrieval Seiso Shine Keep work area clean Seiketsu Standardize Standardize the clean-up (i.e., the first 3 S s). Shitsuke Sustain Develop self-discipline to maintain layout and/or procedures 5S+1 SAFETY Removing hazards & dangers Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
What 5S Looks Like A place for everything, and everything in its place. Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
Value Stream Mapping Lei, S. Lean Six Sigma in Healthcare: Improving Healthcare at Presbyterian Healthcare Services Using Lean Six Sigma. Available at http://www.nmhfma.org/nm_hfma_032411_reg_10_webinar_lean_six_sigma-s_lei.pdf.
Value Stream Mapping Lei, S. Lean Six Sigma in Healthcare: Improving Healthcare at Presbyterian Healthcare Services Using Lean Six Sigma. Available at http://www.nmhfma.org/nm_hfma_032411_reg_10_webinar_lean_six_sigma-s_lei.pdf.
Poka Yoke Mistake-proofing & Error-proofing
What is Six Sigma? An organized, parallel-meso structure to reduce variation in organizational processes by using improvement specialists, a structured method, & performance metrics with the aim of achieving strategic objectives 1 Six Sigma is parallel-meso in that it Operates as a parallel organization, which is the organizational structure dedicated to improving the organization Incorporates both micro and macro level decision making authority that allows multilevel integration of strategic projects Develops formal mechanisms to select Six Sigma projects that involve senior management to identify improvement projects that have strategic or implications and filter out projects that do not have such implications 2 1. Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012 2. Schroeder, R. Six Sigma: Definition and underlying theory. Journal of Operations Management. 2008; 26: 536-554.
How is Six Sigma Different? Structured method (D-M-A-I-C) Teams improve processes on a project-by-project basis using traditional quality tools combined with statistical analysis methods Improvement specialists Levels of training creates hierarchy of problem solvers* Performance metrics Improves & controls processes to ensure they meet specified standards Aim of achieving strategic objectives Projects are tied to a bottom line Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
Six Sigma Problem Solvers Role Upper Management Champions/ Sponsors Master Black Belts Black Belts Green Belts Yellow Belts Responsibilities Promote and provide resources to support Six Sigma efforts Ensure projects are aligned with strategic objectives & provide teams with needed resources & assistance; typically a senior manager that is familiar with Six Sigma approach Provide technical support/mentoring to Black Belts, typically personnel with advanced knowledge of statistics Lead one or more large Six Sigma projects & often work with/mentor Green Belts; often dedicated full-time to project(s) Lead small Six Sigma projects and/or work under Black Belts on larger projects often dedicated Support project work; typically trained in just a basic overview of the tools & methods Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
What Does Six Sigma Mean? Sigma (σ) refers to the symbol used to represent a standard deviation (SD) SD basically describes how much variation is present in some process or outcome SD is calculated as the square root of the average of the squared differences of the values from their average value. A process is said to be operating at a Six Sigma level if it is error-free 99.9997% of the time (i.e., ± 3 SD in a normal distribution) Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
Six Sigma: Before & After Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
Six Sigma s D-M-A-I-C D Define a problem or improvement opportunity M Measure process performance A Analyze the process to determine the root causes of poor performance; determine whether the process can be improved or should be redesigned I Improve the process by attacking root causes C Control the improved process to hold the gains
A Six Sigma Toolbox Define Measure Analyze Improve Control Voice of the Customer (VOC) -Brainstorming -Affinity Diagrams -Nominal Group Technique (NGT) -Multi-voting -Critical-to-Quality (CTQ) Trees -Pareto Charts -Histograms Project Charters -Problem & Mission Statements -Business Case -Key Metrics -Specific Objectives and/or Goals -Scope Definition -Timeline Process Maps -SIPOC -Flowcharts -Swim-lanes Data Collection Plan Measurement Systems Analysis -Precision/Reliability Testing -Accuracy/Validity Testing Baseline Measurements -Basic Statistics -Graphical Methods -Process Capability Analysis 5 Whys/Why-Why Analysis Cause & Effect Diagrams Pareto Charts Hypothesis Testing -T-tests -ANOVA -Correlation -Regression Failure Mode Effects Analysis (FMEA) Design of Experiments Solution Selection -NGT -Multi-voting -Prioritization Matrices Pilot Testing Simulation -Models -Prototypes Planning & Implementation -Management Commitment -Resources -Communication -Process Decision Program Charts Control Plans -Data Needs/ (Variables/Metrics & Frequency) -Specification Limits for Key Metrics -Policies & Procedures Process Monitors Statistical Process Control -Control Charts -Common vs. Special Causes -Sub-grouping -Process Logs -Out-of-Control Action Plan Adapted from Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
Affinity Diagrams Organize ideas into groupings/themes/categories that make sense Involve team members in sorting & grouping Avoid becoming overwhelmed by large number of ideas Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
Process Maps Paccagenella A, Mauri A, Spinella N. Quality improvement for integrated management of patients with Type 2 Diabetes (PRIHTA Project Stage 1). Q Manage Health Care. 2012; 21(3):146-159.
Process Maps Paccagenella A, Mauri A, Spinella N. Quality improvement for integrated management of patients with Type 2 Diabetes (PRIHTA Project Stage 1). Q Manage Health Care. 2012; 21(3):146-159.
Baseline Measurement Histogram Run Chart Pareto Chart Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
Cause & Effect Diagrams Pellicone A, Martocci M. Faster Turnaround Time. Quality Progress. 2006; 39(3):31-36. www.asq.org.
Cause & Effect Diagrams Hina-Syeda H, Kimbrough C, Murdoch W, Markova T. Improving immunization rates using Lean Six Sigma processes: Alliance of Independent Academic Medical Centers National Initiative III Project. The Ochsner Journal. 2013; 13:310-318.
Pareto Charts Institute for Health Care Improvement. Process Analysis Tools: Pareto Diagram, 2004. http://www.physiciansinstitute.org/media/downloads/paretodiagram1.pdf.
Pareto Charts Knowware Quality Improvement Tools : Pareto Chart Examples in Excel. http://www.qimacros.com/quality-tools/paretochart-examples.
Difficulty vs. Impact Matrix BIG PAYOFF/IMPACT SMALL CHALLENGE/DIFFICULTY of Implementation HARD EASY Implement Challenge Possible Kill Palmer, A. Lean Six Sigma Green Belt: Define Stage of Improvement. Presented at the University of Texas Medical Center. September 16, 2013.
Control vs. Impact Matrix Pellicone A, Martocci M. Faster Turnaround Time. Quality Progress. 2006; 39(3):31-36. www.asq.org.
Typical Prioritization Matrix Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
Prioritization Matrix with NGT Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
Control* Chart Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
* In Control vs. Out of Control Process is considered in control when all data points fall within the control limits are distributed randomly Process is considered out of control when Any data point falls outside the control limits Two consecutive points near upper or lower control limits Data points exhibit a systematic or non-random pattern, such as Steady incline or decline ( 6 successive points) Alternating above and below center line ( 14 successive points) Consistently close to the center line ( 9 successive points within +1SD, or 9 successive points within -1SD) Consistently above or below center line, irrespective of distance from line ( 5 successive points) Sudden change in level from one point to next (~+/- 2 SD) Cited by Kovach, J. V., UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma), 2012. Original source: AIAG Manuals for Statistical Process Control (www.aiag.org).
Comparing Lean & Six Sigma Application Focus Approach Lean -Reducing waste/ non-value added activities -Standardizing work -Improving process flow Kaizen events (1 to 3 months) Existing Processes Six Sigma -Reducing process variation -Enhancing process control DMAIC projects (4-6 months) Tools Process-oriented Outcome-oriented/ Data-driven Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
Combining Lean & Six Sigma Evidence suggests Both are effective But, when either used alone, eventuates in diminishing returns Using both simultaneously takes advantage of respective, unique strengths Lean Efficiency + Six Sigma Quality Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012.
II. Applications of LSS in Health Care
Applications of Lean/Six Sigma in Health Care Lean and Six Sigma originally developed for industrial manufacturing to Improve efficiency and quality Contain costs and/or increase revenues Increasingly applied to health care services delivery in recent years DelliFraine JL, Langabeer JR, Nembhard IM. Assessing the evidence of Six Sigma and Lean in the health care industry. Q Manage Health Care. 2010; 19(3): 211-255.
Effectiveness of LSS in Health Care LSS applications in health care consistently reportedly as effective in Improving efficiency OR throughput (planning, scheduling, anesthesia techniques, physician arrival times, surgery duration, etc.) ED throughput (wait times, triage, lab and radiology turnaround, bed availability, registration and discharge procedures, staffing patterns, etc.) Improving clinical outcomes Reducing medication errors (medication, dose, frequency, schedule, route, etc.) Reducing post-surgical and hospital-acquired infections (antibiotic prophylaxis, hygiene practices, etc.) -DelliFraine JL, Langabeer JR, Nembhard IM. Assessing the evidence of Six Sigma and Lean in the health care industry. Q Manage Health Care. 2010; 19(3): 211-255. -Vest JR, Gamm LD. A critical review of the research literature on Six Sigma, Lean and StuderGroup s Hardwiring Excellence in the United States: the need to demonstrate and communicate the effectiveness of transformation strategies in healthcare. Implementation Science. 2009; 4 (35): 1-9.
Effectiveness of LSS in Health Care LSS applications in health care consistently reportedly as effective in Reducing costs/increasing revenue** Decreasing operational costs (e.g., costs associated with filing claims) Decreased staff size Decreasing length of stay Increasing surgical volume -DelliFraine JL, Langabeer JR, Nembhard IM. Assessing the evidence of Six Sigma and Lean in the health care industry. Q Manage Health Care. 2010; 19(3): 211-255. -Vest JR, Gamm LD. A critical review of the research literature on Six Sigma, Lean and StuderGroup s Hardwiring Excellence in the United States: the need to demonstrate and communicate the effectiveness of transformation strategies in healthcare. Implementation Science. 2009; 4 (35): 1-9.
LSS & Cost Savings In manufacturing, Six Sigma has reportedly saved companies millions of dollars Approximately 4-6 projects per year per company Average saving of ~$230,000 per project = Total annual savings of ~$920,000 $1,380,000 to company In health care industry, average per project or total annual savings to health care organizational savings has not been estimated, however Project to reduce length of stay reported >$100K annual savings Project to improve OR throughput reported $350K $500K annual savings Project to reduce medication errors in hospital reported $1.3M in costs avoided Pocha, C. Lean Six Sigma in health care and the challenge of implementation of Six Sigma methodologies at a Veterans Affairs medical center. Q Manage Health Care. 2010; 19(4):312 318.
Effectiveness of LSS in Health Care? Study findings consistently positive Methods usually work? Publication bias? Level of evidence often not strong Weak study designs (e.g., lack of comparison group, brief time frames) Inappropriate analyses Failures to rule out alternative hypotheses Reporting across studies not consistent Breadth vs. depth Cost data often lacking, especially ROI Inattention to changes in organization structure or culture -DelliFraine JL, Langabeer JR, Nembhard IM. Assessing the evidence of Six Sigma and Lean in the health care industry. Q Manage Health Care. 2010; 19(3): 211-255. -Vest JR, Gamm LD. A critical review of the research literature on Six Sigma, Lean and StuderGroup s Hardwiring Excellence in the United States: the need to demonstrate and communicate the effectiveness of transformation strategies in healthcare. Implementation Science. 2009; 4 (35 ): 1-9.
What s Wrong with LSS in Health Care? Industry fit of methods Health care processes often not linear Health care processes often interdependent Patients aren t widgets or machines Implementation issues Unreasonable expectations of leadership and staff leads to burn out or loss of interest Failure to understand & designate required levels of resources (staff, time, etc.) Failure to estimate accurately the expected returns, esp. financial ones Failure to get buy-in from informal leaders & frontline staff Failure to start small and seduce them with success On industry fit, see DelliFraine JL, Langabeer JR, Nembhard IM. Assessing the evidence of Six Sigma and Lean in the health care industry. Q Manage Health Care. 2010; 19(3): 211-255.
What s Wrong with LSS in Health Care? More implementation issues All or nothing thinking about using LSS methods Can leave newly trained staff feeling overwhelmed, especially by complex problems Can lead more highly trained folks toward overkill applying complex tools to simpler problems Closing projects vs. controlling improvements Plans for routinizing changes made and for monitoring key metrics are often inadequate For implementation issues, see: -Goodman J, Theuerkauf J. What s wrong with Six Sigma? Quality Progress. 2005; 38(1): 37-42. www.asq.org -Arthur J. Seduce them with success. Quality Progress. 2005; 38(9): 35-40. www.asq.org -Murphee P, Vath RR, Daigle L. Sustaining Lean Six Sigma projects in health care. Physician Executive Journal. 2011; 37(1): 44-48.
III. Past Applications of LSS Methods in Correctional Managed Care (CMC), Texas
CMC Experience with LSS Increased use of LSS methods at UTMB and other UT Health System entities (e.g., MD Andersen Cancer Center) Several past CMC performance improvement projects clinical safety and effectiveness programs were full LSS projects (see example) Use of various LSS methods by CMC Quality and Risk Management Department Process Mapping/Flow charts Cause and Effect Diagrams Run charts/control charts Histograms/Pareto Charts
Correctional Managed Care Decreasing Infirmary Length of Stay Team Members: Kelly Coates, MBA, Director of Clinical Support Services Jennifer Douglas, Outpatient Services Administrative Manager Cynthia Ho, M.D., MPH, Infirmary Regional Medical Director
Correctional Managed Health Care A strategic partnership between The Texas Department of Criminal Justice (TDCJ) The University of Texas Medical Branch Galveston(UTMB) Texas Tech University Health Sciences Center Focused upon a shared mission To develop a statewide health care network that provides TDCJ offenders with timely access to a constitutional level of health care while also controlling costs
Dalhart Pampa Geographical Areas of Responsibility Amarillo Tulia Plainview 30,684 Offenders* El Paso Lamesa Childress Lubbock Brownfield Colorado City Wichita Falls Jacksboro Bonham New Boston Breckenridge Bridgeport Winnsboro Snyder Abilene Dallas Tyler Overton Venus Palestine Teague Henderson Gatesville Rusk Brownwood Fort Stockton Hondo Burnet Dilley Marlin Midway Lovelady Livingston Bartlett Huntsville Woodville Cleveland Austin Dayton Liberty Navasota Beaumont Kyle Lockhart Houston Sugarland Atascosita San Antonio Richmon Rosharon d Angleton Cuero Brazoria Kenedy Diboll Jasper Texas City Galveston (HG) Beeville Cotulla San Diego Raymondville *Based on FY2010 data Edinburg 120,319 Offenders*
Patient Characteristics, FY2010 Demographics 151,385 incarcerated in approximately 100 facilities 12,010 (7.9%) women 19,251 (16%) 50 years of age or older Prevalence of Health Conditions Hypertension - 36,350 (30%) Hepatitis C - 19,808 (16%) Mental Health Caseload 12,540 (10%) Asthma - 8,980 (7%) Diabetes - 7,795 (6%) Cardiovascular - 2,627 (2%) HIV - 2,365 (2%)
Special Terms Term Definition GP Prison Lingo General Population G3, G4, G5 Custody Levels Free World Off Site HG TDCJ CMC UR Offender / Inmate Infirmary Assisted Living Extended Care NOT prison NOT Hospital Galveston Hospital Galveston Texas Department of Criminal Justice UTMB Correctional Managed Care Utilization Review Patient Nursing home bed Mobile patient Bed bound patient
Background Prior to Hurricane Ike (September 2008), centralized bed management system for infirmary beds located at Hospital Galveston After Hurricane Ike, Hospital Galveston temporarily closed In May 2009, CMC Inpatient Operations Directors formed & audited all infirmaries for May-June 2009 With 97% occupancy rate of our infirmary beds, there was need to increase throughput
Primary Aim To decrease the infirmary average length of stay (ALOS) by 10% during FY10 Important because CMC has a limited supply of infirmary beds and failure to move patients efficiently through these facilities impacts UTMB Hospital Galveston throughput
Other Aims Identify current and future infirmary needs Standardized policies for infirmary placement Optimize use of current beds Management of regional infirmaries
Cause & Effect (Fishbone) Diagram
Priority Matrix N=10 Infirmary Committee Members
Assisted Living LOS FY08-FY10 140 120 100 80 60 40 20 0-20 -40 49 Oct-07 35 30 Nov-07 26 Dec-07 Hurricane Ike 9/08 UCL=60 47 30 28 LCL=11 Jan-08 Feb-08 Mar-08 Apr-08 43 May-08 37 26 Jun-08 Jul-08 Aug-08 37 94 61 Avg=35 Sep-08 Oct-08 62 71 Nov-08 UCL=121 Dec-08 79 54 LCL=16 Jan-09 Feb-09 Avg=69 54 46 Mar-09 Apr-09 104 67 64 May-09 CMC Reorganization into Inpatient and Outpatient Svc Lines Jun-09 Jul-09 49 Aug-09 51 48 50 46 Sep-09 UCL=70 Oct-09 Nov-09 36 Dec-09 4. Dev. Of non-perm list 10/28 2. Revision of Infirmary policies (9/30) Jan-10 29 LCL=12 Feb-10 28 Mar-10 1. Multidisciplinary infirmary rounds (12/1) 31 Apr-10 Avg=41 Reduced ALOS by 41% LOS Avg UCL LCL 3. Monitoring of >60d non-perms (1/10)
140 Extended Care LOS FY08-FY10 Days 120 100 80 60 40 20 0-20 -40 6 Sep-07 Avg=39 42 23 Oct-07 UCL=104 17 Nov-07 Dec-07 Hurricane Ike 9/08 42 39 Jan-08 Feb-08 46 LCL= 27 Mar-08 26 62 Apr-08 May-08 Jun-08 68 Jul-08 75 16 Aug-08 80 Sep-08 52 Oct-08 86 Nov-08 68 60 Avg=66 Dec-08 UCL=118 83 LCL=14 Jan-09 Feb-09 37 Mar-09 71 Apr-09 CMC Reorganization into Inpatient and Outpatient Svc Lines May-09 59 43 Jun-09 86 Jul-09 Aug-09 55 47 37 Sep-09 UCL=66 Oct-09 35 Nov-09 4. Dev. of nonperm list 10/28 2. Revision of Infirmary policies (9/30) 26 32 31 LCL=9 Dec-09 Jan-10 Feb-10 1. Multidisciplinary infirmary rounds (12/1) Mar-10 33 Apr-10 41 Avg=37 LOS Avg UCL LCL Reduced ALOS by 44% 3. Monitoring of >60d non-perms (1/10)
Business Case
Business Case Current Projected LOS Hospital Galveston - Medical LOS (equivalent to Free world LOS) 4 4 - Logistical LOS (time it takes to discharge, place and arrange transport) 2.5 1.5 Total LOS HG 6.5 5.5 Reduced LOS 0 1 # Patients Discharged to Infirmaries Daily 4 4 Cost per Day $1,485 $1,485 Projected Savings per Day $0 $5,940 Projected Savings per Year $0 $2,168,100
Conclusions Length of stay was reduced in CMC infirmaries by actively managing the inpatient infirmary population through Multidisciplinary rounding Individual monitoring Shift in focus from regional oversight to service line orientation created a renewed emphasis on managing capacity within the infirmaries.
IV. Recent LSS Initiatives in CMC
LSS Green Belt Training Recently trained 13 CMC staff members to lead LSS performance improvement projects and diffuse LSS approach throughout organization Hybrid with ~36 in-class hours and up to ~ 40 hours online Conducted collaboratively by faculty from University of Houston School of Technology and from University of Texas School of Public Health Culminating in Lean/Six Sigma Green Belt (knowledge) certification test Full Green Belt status granted after successful completion and presentation of LSS project
Projects In Progress Improving Communication of Urgent Radiology Results Reducing Current and Future EMR Reports Improving TB Screening Rates at Intake
Radiology Project Purpose To deliver timely communication of urgent radiology results so that CMC patients receive timely care Problem Untimely communication of urgent radiology findings have occurred, resulting in delayed care and excess morbidity and costs. Objective To reduce to <=13 business days the total number of days from radiologist reading to provider response for all urgent radiology results by Reducing communication time of urgent results from radiology to a centralized department to <= 1 business day Reducing communication time of urgent results from centralized department to appropriate medical provider to <=2 business days Reducing response time of medical provider(s) to <=10 business days
Radiology Project Key Metrics Number of days from when the radiologist communicates urgent results to centralized department Percentage of urgent results communicated by radiologist to centralized department within 1 business day Number of days from when centralized department communicates urgent results to care provider Percentage of urgent results communicated by centralized department to care provider within 2 business days Number of days from when care provider actively acknowledges urgent results Percentage of urgent results actively acknowledged by care provider after receiving them within 10 business days Total number of days from read-to-response Percentage of urgent results that were both read and responded to within 13 business days
Radiology Project Core Team CMC Six Sigma team members (3) Radiology team members (2) UR team members (1) Tools & Timeline Flowcharts of current and recommended/improved process (Month 1-2) Implementation plan, including communication and training plans (Month 2) Pilot testing of improved process, including data collection and analysis (Months 3-6) Adjustments to process (Month 7) Control plan (Month 8)
EMR Reporting Project Purpose To provide appropriate, accurate, timely information from the EMR that allows management to achieve strategic organizational goals Problem Currently running and distributing approximately 2,400 reports from the EMR, which exceeds optimal functioning capacity of current IT platform/infrastructure No processes in place to request, approve, retain, or eliminate reports Objectives To reduce the number of existing reports to 700 To develop and implement a process for requesting and approving new reports, thereby significantly reducing the number of requested and approved reports
EMR Reporting Project Key Metrics Number and percentage decrease in the number of existing reports Number and percentage decrease in the number of newly requested and approved reports Core Team CMC Six Sigma team members (3) IT representatives (3)
EMR Reporting Project Tools & Timeline Flowcharts of current and recommended/improved process for requesting/approving new reports (Months 1-2) Priority Matrix with NGT to set criteria for approval of new requests (Months 2-3) Develop request form (Month 3) Develop and map process for reducing number of existing reports (Months 3-4) Implementation plan, including communication training plan for newly requested reports AND plan to reduce existing reports (Months 3-4) Pilot testing of improved request/approval process, including data collection & analysis (Months 5-7) Adjustments to improved request/approval process (Month 8) Control plan (Month 9)
TB Screening Project Purpose To complete intake TB screenings for prisoners within 7 days of intake Problem TB screenings completed for only 70% of offenders (on average, monthly) within 7 days of intake at Plane State Jail Poses potential health risks for staff, other inmates, and the community at large Objective To complete TB screenings for 95% of offenders within 7 days of intake at the Plane State Jail
TB Screening Project Key Metric % screened number screened divided by the total intake population (less those known to be TB+) Core Team CMC Six Sigma team members (5) Tools & Timeline SIPOC Diagram (Month 1) Flowchart describing current process (Month 1) Cause & Effect diagram (Month 1) Baseline measurement (Month 1-2) Solution selection (Month 2) Flowchart describing recommended improved process (Months 2) Implementation plan for improved process, including communication and training plans (Month 2) Pilot testing of improved process, including data collection and analysis (Months 3-5) Adjustments to improved process (Month 6) Control plan (Month 7)
Lessons Learned Don t need to use all of the tools, but must use the right tools for the right task/phase Likely DO need to complete all phases of DMAIC, and we have found, especially need to Develop complete & specific plan for initial data collection based on well-designed analytic plan, so don t waste time re-collecting data Work with finance early to determine how saving and gains will be calculated Develop complete control plan, so you don t lose gains of the improvement For monitoring key metrics, plan for ongoing data collection and analysis, frequency of reporting, method of reporting and to whom Strong, clear policies Contingency plans for position vacancies Training plans for new employees
Lessons Learned Create a plan for educating & engaging informal leaders and frontline staff AS WELL as senior leadership Consider communication channels for obtaining improvement ideas from all sectors ideas should bubble up as well as trickle down Small changes can have big impact, so start small & seduce them with success Involve clinicians in LSS, from start to finish, to the extent practical Be mindful of their competing responsibilities Get creative about getting their input
Conclusions Lean/Six Sigma is a systematic performance improvement approach that is being widely used in health care systems throughout the country. Some questions remain regarding about the fit of LSS for health care processes and about exactly how effective LSS is in health care environments Nonetheless, the evidence available to date suggests that LSS methods can be used to improve both effectiveness and efficiency in health care. LSS has been used to improve performance has been used in Correctional Managed Care (CMC) in the past. Based on past experience, recent training, and review of the relevant literature most recent literature, the use of LSS will be improved and integrated throughout the CMC system.
References (in order cited) Kovach, J. V. UH-COT Lean Six Sigma Green Belt Training Manual (www.tech.uh.edu/sixsigma); 2012. Lei, S. Lean Six Sigma in Healthcare: Improving Healthcare at Presbyterian Healthcare Services Using Lean Six Sigma. Available at http://www.nmhfma.org/nm_hfma_032411_reg_10_webinar_lean _Six_Sigma-S_Lei.pdf. Schroeder, R. Six Sigma: Definition and underlying theory. Journal of Operations Management. 2008;26:536-554. Paccagenella A, Mauri A, Spinella N. Quality improvement for integrated management of patients with Type 2 Diabetes (PRIHTA Project Stage 1). Q Manage Health Care. 2012;21(3):146-159. Pellicone A, Martocci M. Faster Turnaround Time. Quality Progress. 2006; 39(3):31-36. www.asq.org. Hina-Syeda H, Kimbrough C, Murdoch W, Markova T. Improving immunization rates using Lean Six Sigma processes: Alliance of Independent Academic Medical Centers National Initiative III Project. The Ochsner Journal. 2013;13:310-318.
References Institute for Health Care Improvement. Process Analysis Tools: Pareto Diagram, 2004. http://www.physiciansinstitute.org/media/downloads/paretodiagram1.pdf Knowware Quality Improvement Tools : Pareto Chart Examples in Excel. http://www.qimacros.com/quality-tools/pareto-chart-examples. Palmer, A. Lean Six Sigma Green Belt: Define Stage of Improvement. Presented at the University of Texas Medical Center. September 16, 2013. DelliFraine JL, Langabeer JR, Nembhard IM. Assessing the evidence of Six Sigma and Lean in the health care industry. Q Manage Health Care. 2010;19(3): 211-255. Vest JR, Gamm LD. A critical review of the research literature on Six Sigma, Lean and StuderGroup s Hardwiring Excellence in the United States: the need to demonstrate and communicate the effectiveness of transformation strategies in healthcare. Implementation Science. 2009; 4(35): 1-9.
References Pocha, C. Lean Six Sigma in health care and the challenge of implementation of Six Sigma methodologies at a Veterans Affairs medical center. Q Manage Health Care. 2010;19(4):312 318. Goodman J, Theuerkauf J. What s wrong with Six Sigma? Quality Progress. 2005; 38(1): 37-42. www.asq.org Arthur J. Seduce them with success. Quality Progress. 2005; 38(9): 35-40. www.asq.org Murphee P, Vath RR, Daigle L. Sustaining Lean Six Sigma projects in health care. Physician Executive Journal. 2011; 37(1): 44-48.