3 rd Lean Six Sigma Symposium Working through the Continuum of Care in Rehabilitation Long Island Chapter of American Society for Quality Carolyn Sweetapple, RN, CPA, MBA Six Sigma Master Black Belt Vice President, Finance and Business Operations March 27, 2009
North Shore-LIJ Health System Manhattan Queens + + + + Suffolk + Staten Island + + + + + ++++ Kings # + + Nassau + + + + + + + + Key: Health System Hospital Competitor Hospital Vital Statistics: 15 Hospitals 5.4 million population served $4 billion in Revenue 33,000 employees slide # 2
Case Presentation Working through the continuum of care in rehabilitation to improve throughput, decrease length of stay and increase revenue using Six Sigma and Lean Methodologies
What is Rehabilitation? Physical medicine and rehabilitation From Wikipedia Physical medicine and rehabilitation (PM&R), or physiatry, is a branch of medicine which aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities. slide # 4
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What is the Rehabilitation Continuum of Care? Hospital-based Therapy Home Care Outpatient Inpatient Rehabilitation slide # 6
Project Selection Criteria Prominent service line for the organization with growth opportunities business case. Each area of product depends upon efficient and effective operations of the other in order to maximize outcome for those patients who move thru continuum- value stream. Data rich environment. Commitment of hospital leadership to enhance/maintain the financial and reputation of the rehab service. Strong local leadership committed to improvement process and sustaining the results. Regulatory and reimbursement shifts in conjunction with above heightened the need to insure efficient service, accurate assessment and high customer service to maximize market share. slide # 7
FOCUS ON HIGH PRIORITY AREAS WITH INEFFICIENCIES AND WASTE slide # 8
Selecting the Methodology Objective: Facilitate process evaluation, process redesign and implementation to improve the flow of patients through the rehabilitation continuum in a community hospital from acute care through acute rehabilitation services and outpatient care. Challenge: How do you decide what methodology to use? ACT PLAN CHECK DO slide # 9
Hospital Based Therapy - PDCA HOSPITAL BASED THERAPY THE ISSUES Regulatory requirements not met Delays impacting length of stay Continuous improvement and monitoring needed WHY PDCA? Use PDCA when you need a dynamic model where completion of one cycle flows into the beginning of the next resulting in continuous improvement slide # 10
The Upstream Impact of Delays in Treatment slide # 11
Problem: Time from physical therapy order to fulfillment exceeds specification of 48 hours. Pareto Diagram 40 35 30 25 20 15 10 5 0 Is s u e 1 Is s u e 2 Is s u e 3 Is s u e 4 Is s u e 5 Is s u e 6 Is s u e 7 Is s u e 8 Is s u e 9 Is s u e 1 0 Is s u e 1 1 Frequency 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Cum ulative Percent Results: Process improvements resulted in turnaround time improvements to a mean of 24 hours 99% of time. Regulatory requirement of 48-72 days assessment met 100% of time slide # 12
Inpatient Rehab - Six Sigma INPATIENT REHAB THE ISSUES Revenue impact significant Causes and solutions not apparent Cross functional issue Previous improvement efforts only yielded partial success WHY SI SIGMA? Changes in culture needed for full efforts to be realized Concerted cross functional effort needed Redesign of current system needed Strong financial business case to deploy the resources needed slide # 13
DEFINE Project: Current processes are not allowing us to accurately assess patients functional level and therefore the burden of care. This results in higher FIM scores which reduces Medicare reimbursement. Customer Demands: Improve assessment accuracy Improve documentation accuracy Increase revenue per patient Increase patient volume Expedite admissions FIM SCORE 90 80 70 60 50 40 30 20 10 0 Admission FIM Scores Ortho Stroke Brain Med Complex Southside 89.6 65.9 63.4 85.6 Regional 80.6 61.4 59.4 75.7 National 76.1 59.2 58.6 69.7 Southside Regional National Benchmarking against regional and national averages revealed that our hospital was statistically significantly higher in scoring. slide # 14
Problem Measurement and Data Gathering: MEASURE Defect was defined as Assessment scores not measured all three days of patient admission using standardized algorithm. FIM Item # 2 3 4 Description Grooming Bathing Dressing-Upper Internal variance Other system hospital variance Regional variance Medical record reviews were performed and therapists were shadowed to quantify defects. 5 6 7 8 Dressing-Lower Toileting Bladder Bowel 9 Bed. Chair 160 140 Number of pts. Assessed 10 12 Toilet Walk/wheelchair 120 100 80 60 40 20 0 Day One Day Two Day Three Results: 65% of the time we do not meet our customer s specifications Goal: Reduce defects from 65% to 20% slide # 15
Identifying independent variables that determine CTQ behavior: Process Analysis & Data Analysis ANALYZE 160 140 120 100 80 60 Number of pts. Assessed Critical s 1= Delay in admission after acceptance 2= Assessment not performed until day 2 40 20 0 Day One Day Two Day Three 1 2 3 Total 1 0 149 48 197 65.67 65.67 65.67 2 197 48 149 394 131.33 131.33 131.33 Total 197 197 197 591 Chi-Sq = 65.667 +105.753 + 4.753 + 32.833 + 52.876 + 2.376 = 264.259 DF = 2, P-Value = 0.000 3= Assessments not performed on all 3 days 4= No standardized process followed to perform assessment 70 60 50 40 30 20 10 0 % SCORI slide NG# 16 VARIANCE 6 9 5 8 7 2 10 3 65 45 44 40 39 36 36 29
Improvements Implemented: Patients admitted day of acceptance rather than 2 or more days later Admission times before noon, rather than late afternoon Standardization of process Reassessment process, which includes assessment of patient on day 1 of admission, as well as day 2 and day 3 IMPROVE Results: The defect rate was reduced to 10% resulting in $500,000 additional revenue for the hospital annually Chi-Square Test: DAY 1, DAY 2, DAY 3 Expected counts are printed below observed counts DAY 1 DAY 2 DAY 3 Total 500 450 400 350 300 250 200 150 100 50 0 1 79 147 195 421 # Lowest score 140.33 140.33 140.33 # Non-low est score 497 2 497 429 381 1307 429 381 435.67 435.67 435.67 Total 576 576 576 1728 Chi-Sq = 26.806 + 0.317 + 21.295 + 195 147 8.635 + 0.102 + 6.859 = 64.014 79 DF = 2, P-Value = 0.000 DAY 1 DAY 2 DAY 3 slide # 17
CONTROL Ensuring Sustainable Results: Changes imbedded in departmental processes Owners continue to monitor with control charts and intervene if trends are observed Defect Rate 100 50 0 0 10 20 30 40 50 60 Sample Number UCL=92.38 U=64.6 LCL=43.02 Goal = 20 Actual = 9 Tools Used: Control Plan SPC Risk Assessment Plan Communication Plan Results: Results were sustained and revenue gains continue to be realized slide # 18
Outpatient - Lean OUTPATIENT PHYSICAL THERAPY THE ISSUES Delays in access time. These delays caused further inefficiencies and lost business no shows and cancellations. Capacity constraints limited growth in volume although demand existed. WHY LEAN? Improve what exists (process improvement) by removing waste and non-value added steps. If you see queues or disorder, think LEAN. Lean improvements create flow and throughput. slide # 19
Ambulatory Rehabilitation Access to to Care Project Description: To To create an an integrated outpatient service that that responds to to the the needs of of our our patients and and physicians, is is effective and and efficient and and can can adjust to to changes in in the the therapeutic environment. Intake Intake Insurance Insurance Verification Verification & Registration Registration Scheduling Scheduling Clinical Clinical Intervention Intervention Charge Charge Input Input Patient Patient Discharged Discharged Access to Care (COR) Pre-improvement Process Data LS L * Target * USL 96 S am ple M ean 169.648 Sample N 25 S td ev (Within) 74.4552 S td e v (O v e ra ll) 88.40 22 0 USL 100 200 300 400 Within Overall P ote ntia l (W ithin) C a pa bility Cp * CPL * CPU -0.33 Cpk -0.33 CCpk -0.33 O v e ra ll C a pa bility Pp * PPL * PPU -0.28 Ppk -0.28 Cpm * Mean of 169 hours Standard deviation of 88 >79% of cases exceeded the target of 96 hours O bserv ed P e rform a nce % < LSL * % > USL 84.00 % Total 84.00 Exp. Within Performance % < LSL * % > USL 83.87 % Total 83.87 Exp. O verall Performance % < LSL * % > USL 79.76 % Total 79.76 slide # 20
Patient contacts department (telephone) Patient contacts department (telephone) Back to phone Schedule appointment Walk in Preregistration Preregistration Back to phone Schedule appointment Walk in Courtesy call to patient Obtain Dx / problem Information entered into Spectrasoft BEFORE LEAN Give patient instructions / directions ID insurance carrier Non-par Refer out Insurance cards, ID and script copied Verification, authorization, precert Patient put on hold PAR Self pay pricing No Phone conversation completed Call insurance Walk in Product line triage Yes Intake form copied Intake book PFS Demographics SSHI Copy to Margaret Intake form filled out COR Call ends Stat Sheet Overproduction Waiting Stat sheet to Donna Entered into spreadsheet Information forwarded to manager Manager reviews and determines schedule Call back patient BEFORE LEAN: Access to outpatient services averaged 169 hours exceeding customer specification of 96 hours Customers dissatisfied and business lost >79% of cases exceeded the target of 96 hours Registration AFTER LEAN AFTER LEAN: Access to outpatient services averaged 100 hours Eliminated 11 steps Saved $45,000 per year in labor costs Improved access to care by 3 days Courtesy call to patient Obtain Dx / problem Information entered into Spectrasoft Give patient instructions / directions Verification, authorization, precert Registration slide # 21 ID insurance PAR Product line carrier triage Yes Non-par Self pay pricing No Demographics Refer out Insurance cards, ID and Walk in script copied Patient put on hold Phone Intake form conversation copied completed Intake book Call PFS insurance
R E S U L T S HOSPITAL BASED THERAPY - PDCA Regulatory requirements met Length of stay decreased Turnaround time improved to a mean of 24 hours INPATIENT REHAB - SI SIGMA IMPROVEMENTS Additional revenue of $ 500,000 annually realized Admission to acute rehabilitation services from the hospital improved from 10% to 50% after intervention on day one OUTPATIENT PHYSICAL THERAPY - LEAN Access time improved from 6 days to 3 days No show/cancellation rate improved from 18% to 12% Staff productivity allowed for increased capacity without additional costs slide # 22
C O N C L U S I O N S The use of Clinical Audit tools with Six Sigma and Lean methodologies were effective to improve performance in rehabilitation services in a community hospital. This explicit and detailed use of the complementary methodologies to efficiently and effectively move patients through the continuum of care is easily replicable to other health care environments. slide # 23 Copyright 2009, 2008, Krasnoff Quality Management Institute
Characteristics of Effective & Sustainable Projects Project scoping Leadership commitment Strength of process owner Identification of barriers (people and resources) early with a plan to address Sensitivity of political environment Correct identification of vital independent variables Strength of improvements Change management efforts Ease of measurements slide # 24
Questions? slide # 25
The Krasnoff Team Led by Yosef D. Dlugacz, Ph.D. Diverse team composed of: Six Sigma Master Black Belt & Green Belts Chief Nurse Executives Certified Public Accountant Quality Management Executives Case Management Specialists Registered Nurses Communication Specialist Physician Research Analysts Data Analysts Program Manager slide # 26
Questions? For additional information, please visit our web site at www.thekqmi.org or Contact us directly: Krasnoff Quality Management Institute 600 Northern Boulevard, Suite 220B Great Neck, New York, USA 11021-5200 516-465-8440 kqmi@nshs.edu Thank you! slide # 27