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International Journal of Advances in Science Engineering and Technology, ISSN: 2321-9009, Vol-4, Iss-3, Spl. Issue-1 Aug.-2016

Applying Lean Six Sigma Improvement Methodology to Increase Catheterization Laboratory Efficiency

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APPLYING LEAN SIX SIGMA IMPROVEMENT METHODOLOGY TO INCREASE CATHETERIZATION LABORATORY EFFICIENCY

1BERNA UMUT, 2PEIMAN ALIPOUR SARVARI

1Awentiagroup Healthcare Consulting, CA, USA

2Industrial Engineering Department, Istanbul Technical University, Turkey E-mail: 1 [email protected], [email protected]

Abstract- Coronary diseases have increasing trend in many countries. Considering increasing number of patients and cases, improvement projects are getting crucial at catheterization laboratories. We took a close look to our catheterization laboratory operations from patient admission until discharge. We have initiated lean six sigma implementation at our catheterization laboratory starting with January 2013. This study shows the plans and results between June 2013 and December 2014. As a basis of this study, we have measured the time spent by patients at each processes from admission until discharge in the second half of 2013 during catheterization laboratory operations. We realized patient-waiting time, late start of first procedures and procedure cancellations are the biggest problems. We made root cause analysis and in parallel patient satisfaction surveys were also pointing out dissatisfaction was dramatically increased due to long waiting times. We worked on improving process flow, making it smoother and steadier through work stream, and eliminating waste in years continuously with a plan. Procedure types remained same but number of procedures performed was increased. Wastes in the processes were dramatically decreased; we saved time and created capacity into current catheterization laboratory operations by using continuous improvement techniques with our staff. Although we have employed two non-clinical staff titled ”catheterization laboratory service manager", and “material analyst”, number of patients treated in the same catheterization laboratory was increased in 2014 comparing with 2013. Keywords- Catheterization laboratory, Healthcare, Lean six sigma, Operational efficiency, Patient pathway, Toyota I. INTRODUCTION Catheter laboratories (Cath Labs) could be one of important but most costly area of the hospital although may look like many of determining factors are already known. Analyzing and identifying the root causes of inefficiencies could be challenging if there is not any major problem seen. Improving operational efficiency by eliminating redundancies and streamlining the workflow at the Cath lab and prior the Cath lab starting with outpatient clinic is helpful to reduce different type cost items (Agarwal et al., 2015). Cath Labs are integral part of hospitals. They are high volume, challenging and complex environments within the hospitals. In a busy Cath lab settlement there is a serious need in efficiency programs that a specialized expert can give training to hospital staff on how to approach and solve these issues at source. Also between delivering service and commodity there are big differences and difficulties (Bhat, Gijo, & Jnanesh, 2016; Cost, 2009; Fernandes, Daya, Barry, & Palmer, 1994; Tyson, 2010). Different than commodity, perceived value creates satisfaction after service has consumed. Personal interaction between consumer and the provider creates a strong satisfaction or repurchase decision from the same service provider for same or similar need. Service representatives may create variation in satisfaction level during service provision (Parasuraman, Zeithaml, & Berry, 1985). The Parameters while reselecting the same service provider would be mainly the provision of consistent and reliable service, trust and completion of a service

delivery. Improvement in healthcare service quality parameters also directly correlated with increase in patient satisfaction. And high level patient satisfaction also brings patient retention and loyalty besides (Flaherty et al., 2015). As De Koning et al. (2006) explained, the cost of medical care as a service sector is increasing at an alarming and unsustainable rate worldwide. Admittedly, a significant percentage of these cost increases can be attributed to an aging population and technological advances. These two factors, inevitable because of the technological and demographic developments of modern society, are largely beyond control. However, another significant source of healthcare cost increases can be broadly characterized as unnecessary operational inefficiency. Healthcare professionals have more control over this factor. Inefficiency can be measured and changes implemented to improve quality. These efforts provide more affordable and better healthcare for a large percentage of the population (de Koning, Verver, van den Heuvel, Bisgaard, & Does, 2006). As Corbin et al. (2001) presented, Operational inefficiency is ubiquitous to most current healthcare delivery systems. Some of these operational inefficiencies arise due to impediments and redundancies in the direct medical service delivery process. Others seem to be associated with the logistical, administrative and operational aspects of the healthcare delivery system. Both of these areas are amenable to systematic process innovation and improvement activities. It is well known that improvement in healthcare service quality results in an improvement in patient satisfaction (Corbin,



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Kelley, & Schwartz, 2001). Our target and attempt is minimizing inefficiencies, maximizing Cath Lab utilization at each patient pathway, and minimizing cost. For us, this is very critical to be able to offset declining reimbursement. To be able to eliminate redundant non-value added activities during continuous process improvement using lean six sigma approach is most popular technique for several reasons. This paper is organized as follows. Section 2 describes our proposed methodology to solve mentioned problems. Case study, computational results and comparisons are presented in Section 3, followed by conclusions in Section 4. II. METHODOLOGY 2.1. Study Population This study covers 30 different procedures and majority is elective (80%) than urgent cardiac catheterization (20%) with dominance coronary angiography, coronary angioplasty with BMS, coronary angioplasty with DES, peripheral angiogram, and other heavier procedures performed in between June 2013 and December 2013. Emergency procedures also kept included into study. 2.2. Lean Thinking and Change Management Lean Thinking principally known as the Toyota Production system, originated by Japanese Automotive industry in 1988 by Ohno and facilitated by the publication of Womack, Jones, and Roos to Western traditions in 1996. Lean is stated in simpler, faster and cheaper solutions and work streams. Also, main assumption is “thinking” or “doing” things in most “effective” and “efficient” way. While lean is more about speed and efficiency and ensures that resources are working on the right and standardized activities, six sigma is more about precision and accuracy and ensures things are done right the first time. LSS is a proven methodology mainly in manufacturing and several industries and also not new its applications in healthcare practices. LSS is essential to establish continuous improvement culture and treating patients with higher quality of care by reducing operational costs and enhancing patient safety in first place (Swartz, Hudson, & Graban, 2013).

This section discusses the methodology adopted for this research. We have used LSS and change management techniques to improve throughput and efficiency. We have collected 6 months long data before defining the problems and before not going into the conclusion immediately. According to data collection plan, data has collected from admission until discharge for every single patient. We have grouped and analyzed data as before procedure, between the procedures, knife to skin until gloves off and time spent till discharge. Collected data were analyzed using lean tools, decision making and problem solving tools were applied. Current and future Value Streams were mapped (VSM), A3, and Spaghetti diagram were used to analyze data for current and future states. Hoshin kanri (strategic direction setting), Heijunka (level loading of work and patient demand), 5S, visual management, Mistake proofing, Kanban, Just in time and work standardization are other lean tools used during this study We aimed improving the efficiency and the patient throughput, in the context of a busy, challenging and complex Cath Lab workflow setting by using the impact of lean six sigma implementation. Although we focused on the various cycle times impacting efficiency and patient satisfaction components, we have started with priorities and quick wins to start with the journey. III. CASE STUDY 3.1. problem statement Our one Cath lab city hospital operates under a big health delivery chain. In the year 2012, our Cath lab had 26% increase in procedure numbers with the suburban patients. Cath lab started continually working overtime, cost increased and staff was wearied down. Despite of working long hours, time and effort we spent, and increasing operational cost, our patients were getting increasingly unhappy. Annual customer satisfaction survey was giving alarm by showing disappointment and reduced loyalty results. Hospital continued treating more patients continually in years 2013 and 2014 as shown in Figure 1

.

Figure 1. Number of procedure development in 2012, 2013, 2014

3.2. Understanding and Analyzing the Current State Initial study was setting Hoshin Kanri workshop with top management and creating awareness and aligning

on the strategical components before setting clinical, financial and satisfaction level KPIs. Top management has embraced continuous improvement mindset for several reasons and under their strong



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leadership Cath lab staff volunteered joining trainings and improvement projects. Three improvement project teams were set up. A focus group study helped us understanding patients’ expectations and needs through our Cath lab service and therapy delivery pathways. Activities were classified as value added and not Value added from the eyes of patients. An internal assessment was done and team mapped the current value streams and SIPOC diagrams as well as spaghetti diagrams and A3 tables as a primary analytical tool of lean Six Sigma process improvement methodology. It helped identifying potential bottlenecks in a continuous process line so we used those as major input during project selection. The sequence itself and the each process contain both value added and non-value added activities naturally in the current material and information flow. Current process flow contains potential redundancies, bottlenecks and unnecessary time and effort spent without any value addition that we can call those waste. Accordingly, improvement team prepared a data collection and measurement plan. Database was created starting from June 2013 until December 2013 by collecting time-stamps for each patient before and after operation. Number of total procedures in our single Cath lab was 1994, 2451, and 3192 in the calendar years 2012, 2013, and 2014. Initial analysis shown that, 324 procedures started with delay out of 1250 data in the second half of 2013. When we went into delay breakdown that current work stream created were mainly from the “late blood test results” if patient doesn’t have the recent one. Second majority was

“procedure rescheduling” during the day since current Cath lab also accepts emergent patients during the day. Third majority was “procedure cancellations” by patients and followed by others as shown in Figure.2.

Figure 2. Delay break down representing second half of 2013

3.3. Improvement Time spent during the procedure by operator was out of scope during all improvement efforts. However, we have measured the time spent during each procedure types and analyzed the variation between cardiologist teams. Initially we have expected increasing patient satisfaction and reducing cost of overtime expenses by eliminating procedure cancellations, eliminating late start of first procedure for a better procedure run during the day, and shorter length of stay as shown in Figure.3. We have prepared a continuous improvement plan and initially aimed “reducing all kind of waste to half from the system”.

Figure 3. Initial continuous improvement targets

Continuously, we aimed to reduce waste over 90% from the system in years. Performance management of the current Cath lab was also improved by hiring “Cath lab efficiency manager” with responsible of overall efficiency improvement and performance monitoring and leading procedure and material management committee at the hospital. Other hire titled as “material analyst” also permanently joined improvement activities with responsibility of reducing material and supplier related inefficiencies

and cost items. Both have taken over several burdens from cardiologists’, nurses’, technicians’, nurse manager’s, and procurement manager’s shoulder. An equipment analyst also joined to improvement efforts temporarily based. We were supported by a professional consulting firm for planning and implementing continuous improvement efforts, change management and Lean Six Sigma know how. Whole process line was redesigned to be able to eliminate waste. Initial target was cutting everything



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in half by using lean techniques continuously. Cath lab processes, and activities analyzed, job descriptions of all staff were re-identified. A call center agent was hired to inform Cath lab patients 24h before their visit to remind appointment time and

necessary documentation and initial registration and follow-up calls after the procedures are also call center agent’s job. Figure 4 shows the Cath lab assembly line designed in our study.

Figure 4. Cath lab assembly line

Figure 5. Process improvement actions through a timeline

Improvement teams were also a natural member of change management team. A professional consultant and Cath lab service manager led the chance management through the first two years of journey End to end work stream was restructured and changed in accordance with Toyota assembly line mindset. In continuation of this study, patient pathways will be identified. Current procedure time each step were measured and variation between working groups were identified. Reasons were analyzed and supported with trainings and staff turnover also dropped more than half until 2015. Figure 5 shows the timeline of our journey in 2013 and 2014. When we take a look the journey between years January 2013 and September 2014, it might be helpful to initiate lean improvement milestones.

CONCLUSIONS AND FUTURE WORK In this study Lean Six Sigma techniques were used to leverage overall efficiency of Cath lab operations. Dedication of top management and cath lab staff and, on time change management actions helped maximizing the success of this study. Main deliverable was increasing patient satisfaction by reducing waiting times and also improving overall efficiency so hospital can deliver care continuum to more patients in need without compromising from clinical quality and safety. In 2012, single cath lab was serving to 6patients/day, 8 patients/day in 2013 and 11 patients/day in 2014 as shown in Figure-1. This study also leveraged increasing staff satisfaction and reduced turnover. Trained clinical staff is a big



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asset during continuation of service delivery in healthcare and there are difficulties sourcing them. Work standardization was created by using lean methodology after every phase of improvement. This has been using as training material for new hires. Initial high impact projects were followed by other projects in different areas to maximize overall cath lab efficiency. We saved time and created capacity into current catheterization laboratory operations by using continuous improvement techniques with our staff. Patient flow,

cath lab utilization, capacity freeing up, full time employee utilization, equipment up time, material and staff over time cost also improved. Although we have employed two non-clinical staff titled ”catheterization laboratory service manager", and “material analyst”, number of patients treated in the same catheterization laboratory was increased in 2014 comparing with 2013. Overall results are summarized at Figure 6 For the future work we will be improving overall work stream by reducing wastes continuously.

Figure 6. Key improvements and their results

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