What are the current best practice models and opportunities for driving efficiency (revenue/cost, work/product/time) our care? Lisa Yerian, MD May 12, 2011
Efficiency Extent to which time or effort is well-used for intended task or purpose Capability to produce an outcome effectively with minimal waste Input to output relationship Efficiency Effectiveness
Efficiency Measure of work relative to time, effort or resources - Services performed per hour - Or, Hours per unit (HPU) - Eg., 1 Tech hour per 50 tests Efficiency gains reduce time to perform an amount of work (eg., 50 tests), or increase # tests the tech can perform in an hour
Efficiency Improved efficiency important because it drives the value equation, because the resources (input, such as FTE) cost $ - Value = quality/cost - Efficiency gets more done in less time, from a given amount of resources, therefore decreasing cost
How to improve efficiency? Set goals Measure Take steps to improve Reward/recognize improvements
Continuous Improvement Cycle Set Goals Measure / Review Performance Improve Reward / Recognize Culture to Sustain Repeatable Cycle to Improve Performance
Continuous Improvement Cycle Incremental improvements in performance, repeated and sustained Process improvement Process improvement Process improvement
Continuous Improvement Cycle Set Goals Measure / Review Performance Improve Reward / Recognize Culture to Sustain Repeatable Cycle to Improve Performance
Where do goals come from? Benchmarking Historical performance Regulatory/compliance Business need Process need (rate of pull ) Medical/other customer need Aspirational May be set at individual, work area, dept level
Continuous Improvement Cycle Set Goals Measure / Review Performance Improve Reward / Recognize Culture to Sustain Repeatable Cycle to Manage Performance to Goals Align Ability to Act w/ability to Measure (inform)
How do we measure? Various techniques and levels of visibility Department/cost center - Time per unit (Hours per Service) - Helpful to manage budget/expenses b/c accounts for all resources consumed - Helpful if waste appears to be outside of task Specific process or task level - Greater visibility to actual work - Finer detailed analysis - Process mapping, manual timing
Process Mapping Provides detailed outline of all steps involved in a process Good when: - Process is complex - Steps are not well-understood by the folks involved - Process spans multiple workgroups Process map illustrates opportunities for improvements ( kaizens )
Client information Could be missing Courier Drop off to CPA and sort Get specimens AP Billing Process Map CPA could mis-sort CPA Track to Gajema containers Sort to bins Surg Path Accession Bring copy of req. to scanning daily Accept in Gajema, accession Cytology Accession Bring copy of req. to scanning daily Accept in Gajema, accession = Billing Requisition Movement APCS Accession Bring copy of req. to scanning daily Accept containers, accession = Weak Connection GI Consults Accession Bring copy of req. to scanning daily Accept in Gajema, accession Sign Out Sign out case No standard process for getting copy of req. to scanning Bone Marrow Accession Send to Flow Accept in Gajema, accession 1 Day 1 Day 1 Day 1 Day 1 Day 2 Days 2 Days 1 Day IHC Accession Send slides & paperwork to molecular Accession, cut slides Req. copies not Bottleneck at going to scanning billing Molecular Scanning to Billing Coding Billing Testing On-Base Batch File reqs., Code and bill Get and enter Compile give copy to in Co-Path demographics and APCS info perform Scan batch validating and index Print sign Print function in Testing out log accession Co-Path & error log 1 Day 1 Day 1 Day 5 Days 25 Days 1 Day Key Observations: CPA could mis-sort Client information could be incomplete Fuzzy connections between Bone Marrow, IHC, and Flow Bottleneck at billing process
35 30 25 20 15 10 5 0 AP Billing Process Map Analysis CPA Accession Scanning Sign Out Coding Billing Current Actual Proposed Actual Current Cumulative Proposed Cumulative Courier Lead Time (Days)
AP Billing Process Map Analysis 35 Lead Time (Days) 30 25 20 15 10 5 0 Courier CPA Accession Scanning Sign Out Coding Billing Current Actual Current Cumulative Proposed Actual Proposed Cumulative *Goal: Reduce billing lead time from 29 to 9 days
Can we do this?
Analysis Calculate takt time Available time/customer demand Beat or pace required to meet demand Can we meet demand of 2215 cases/month?
Analysis Calculate takt time Available time/customer demand Beat or pace required to meet demand Can we meet demand of 2215 cases/month? 8.5 hrs 2.85 hrs (lunch/pto/ mtgs)=5.65 hrs/day 2.25 FTE x 5.65 hrs/day = 16,590 min/month 16,590 min/2215 cases = 7.5 min/case For billing to keep up with demand, need to bill a case every 7.5 minutes
Time Study Analysis
Time Study Analysis Calculate cycle time for billing a case AP Billing Takt Time vs. Cycle Time Analysis 3.9 min: Normal cycle time 0.6min: Variation cycle time 1.3 min: Incidental cycle time * 5.8 min Net Cycle Time Time (minutes) 8 7 6 5 4 3 2 1 0 1.3 0.6 3.9 incidental cycle time variation cycle time normal cycle time takt time
Time Study Analysis Calculate cycle time for billing a case Therefore, we should be able to AP Billing Takt Time vs. meet the 7.5min per case Cycle Time Analysis demand! 3.9 min: Normal cycle time 0.6min: Variation cycle time 1.3 min: Incidental cycle time * 5.8 min Net Cycle Time Time (minutes) 8 7 6 5 4 3 2 1 0 1.3 0.6 3.9 incidental cycle time variation cycle time normal cycle time takt time
Continuous Improvement Cycle Set Goals Measure / Review Performance Improve Reward / Recognize Culture to Sustain Repeatable Cycle to Manage Performance to Goals Align Ability to Act w/ability to Measure (inform)
How to improve efficiency? Work harder/faster? -? Feasibility -? Defects
How to improve efficiency? Work harder/faster? -? Feasibility -? Defects Identify and eliminate waste in all its forms
Forms of Waste TimWood-U T - Transportation I - Inventory M - Motion W - Waiting O Over-production O Over-processing D - Defects U - Underutilization
Lean Methodologies Set of tools aimed at eliminating waste Endorsed by JCAHO 5S is a lean tool used to remove all physical waste from the workspace Spaghetti diagrams highlight wasted transportation
Laboratory Workstations Lean Standard Work 67 lab employees 100 s of wastes Revolutionary new building layout
67 Lab Employees in series of 2day events
New Building Laboratory Workstations Eliminated 100s of wastes Moved from 62 91% tasks located within Lean work area Standard Work 67 lab employees 100 s of wastes Revolutionary new building layout
Lean Methodologies Set of tools aimed at eliminating waste Endorsed by JCAHO 5S is a lean tool used to remove all physical waste from the workspace Spaghetti diagrams highlight wasted transportation Value Stream Mapping is a lean tool to identify waste in processes
Value-Stream Mapping Process mapping with time and value information layered on Value defined by the customer s perspective not by what we think is valuable Customer = Patient/recipient Way to identify waste in processes and spend time on what is valuable to patient
Waste Reduction & Lean 1% Typical Company 99% Original Lead Time Traditional Improvement 0.5% 99.5% Lean Waste Reduction 10% 90% Minor Improvement Major Improvement Value-Adding Activities Non-Value-Adding Activities
Value Stream Mapping Current State Value Stream Map We need to have a deeper understanding of what occurs today and where the opportunity is
Surgical Pathology Biopsy Processing: Current State Log Printout 7 am and 9:30 pm Log Printout 7 am and 9:30 pm Co Path Special Stain EPIC Data Input RTFT Value % Defects Value % CT 90 Min Specimen Delivery 88 Specimens Every 60 Min Create smaller more frequent batches 7am and 4 pm 8 am, 5 pm, 6:30 pm, 10:30 pm Reduce CT at Embedding / QA by defining standard work Every 40 Min LT People Hrs. Op. Volume Name Value Min.75 ea 5 am 6 pm Hrs 228 Unit Value Unit Every 15 Min Reduce LT from Slide Distribution To sign off Every 15 Min Transcription Accession RTFT 75 % Defects Value % CT 4 Min LT 117 Min People 2.5 ea 3:30 Hrs. Op. am Hrs 6:30 pm Volume 367 Pts??? Value Unit Reduce LT from Receipt to Accession by Accessioning at night 70 80% of volume delivered Between Noon and Midnight Processing/ Grossing RTFT 85 % Defects Value % CT 9 Min LT 128 Min People 6 ea 4:30 Hrs. Op. am Hrs 9:30 pm Volume 380 Bloc???? Value Unit Tissue Processing RTFT 87 % Defects Value % CT 65 Min LT 193 Min People 13 ea Hrs. Op. 7 pm 5:30 pm Hrs Volume 380 Bloc??? Value Unit Embedding / QA RTFT 98 % Defects Value % CT 10 Min LT 218 Min People 4.5 ea Hrs. Op. 9 am 3:30 pm Hrs Volume 380 Bloc???? Value Unit Slide Production RTFT 90 % Defects Value % CT 20 Min LT 251 Min People 4.5 ea Hrs. Op. 5 am 6 pm Hrs Volume 532 slid???? Value Unit Slide Distribution RTFT 95 % Defects Value % CT 32 Min LT 218 Min People 4.5 ea 88 Specimens 33 Cassettes 320 Cassettes 125 slides 160 Slides 60 Cases Reduce LT by dictating while grossing Define Material Flow Hand-offs Block To File Hrs. Op. 5 am 6 pm Hrs Volume 760 Slid???? Value Unit Process Paperwork RTFT 99 % Defects Value % CT.5 Min LT Value Min People 0 ea Hrs. Op. 5 am 6 pm Hrs Pathology Sign Out RTFT 50 % Defects Value % CT 11 Min LT 481 Min People Value ea Hrs. Op. 8 am 5 pm Hrs Volume 367 Pts???? Value Unit Reduce LT on residence preview time Slides to File Volume Name 367 Pts Value Unit 117 Min 128 Min 193 Min 218 Min 251 Min 218 Min 481 Min Total LT = 1606 Min 4 Min 9 Min 65 Min 10 Min 20 Min 32 Min 11 Min Total CT = 151 Min VA / NVA = 9.4%
Value Stream Mapping Current State Value Stream Map We need to have a deeper understanding of what occurs today and where the opportunity is Future State Value Stream Map We need to develop a vision for what the future looks like Gap Closure Plan We need to develop a plan to go from current to future
Team Feedback I actually got a lunch break! Can we keep it this way? If I had a question, I could just turn around and ask Sam I saw why it was important to cut it this way I found out I was the bottleneck! We had to get help with my work. Wow we can actually DO this!
Trial Runs in Temporary Cell Throughput Time for a Biopsy Before Trial Run Trial Week of 3/30 Trial Week of 6/15 0 100 200 300 400 500 600 700 800 900 Throughput Time (minutes) Received to Accessioned Accessioned to Histology Entered Histology Entered to Gross Complete Gross Complete to Off Processor Off Processor to Embedding Complete Embedding Complete to QA QA to Block Cut Block Cut to Off Stainer / Coverslipper Off Stainer / Coverslipper to Slide Labeled Slide Labeled to Match Paperwork Match Paperwork to Slide Delivered
Project Target Sheet Kaizen Workshop Target Sheet Division Name: Anatomical Pathology Department Name: Anatomical Pathology Team Name: Biopsy Cell Design 2009 Date: 15-Sep-09 (A) Current State (B) Target (G) Proposed Cell (H) Difference (I) % Improvement Space (Sq. Ft.) 920 Red 50% 1090 (170) -19% TAT: accession to delivery - avg final trial (min) 815 280 600 215 26% TAT: accession to delivery - best final trial (min) 815 280 305 510 63% % Signed out by day after receipt 76% 80% 84% 8% 11% Volume Per Day (biopsies parts/day) 446 446 446 N/A N/A Full-time Equivalent Crew 19 15 15 4 21% Productivity (Bx/Hr) 2.9 4.4 3.7 0.8 28%
Lean Biopsy Cell Design
All Levels Drive the Cycle! Leadership Middle Mgmt Front-line
Leadership s Role Set goals and direction Make sure performance is reviewed Reward behaviors and results Model and reward Serving Leader behaviors Make tools accessible Thank them for doing this!
Middle Management s Role Identify, understand value-stream Help and encourage team to identify problems, waste, solutions Learn available tools Reward participation and results Embody Serving Leader principles Thank them for doing this!
Front-line s Role Participate! - in improvement initiatives and events Identify waste Raise issues/problems Make suggestions for improvement Regularly review performance Brainstorm possibilities Thank them for doing this!
Challenges Sponsorship critically important The activity is a statement about the current state there is often sensitivity to that statement. The show must go on Have to figure out how to do this work without disrupting routine work Resentment of folks not on the team, particularly if they are doing extra work. It s hard work! (acknowledge that)