Kaizen HospitalPatient Satisfaction Analysis

Global Consulting Detectives

Iris Nibbs, Aleena Narithookil Chung Hua (Ed) Ho, Devin Ng, Alice Nguyen, and Rachel Pierson

9 March 2015

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Table Of Contents

Introduction............................................................................................................................................. 3

About Kaizen........................................................................................................................................... 4

Business Goals and Objectives............................................................................................................ 4

Project Scope........................................................................................................................................... 4

Project Constraints................................................................................................................................ 8

Project Assumptions.............................................................................................................................. 8

Solutions................................................................................................................................................... 8Discharge Process............................................................................................................................................... 9Employee Interaction...................................................................................................................................... 11Cafeteria Solution............................................................................................................................................ 14

Project Team......................................................................................................................................... 17

Lessons Learned................................................................................................................................... 18

Conclusion............................................................................................................................................ 19

Works Cited/Referenced................................................................................................................. 20

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Executive Summary

Throughout analyzing the survey data provided by the customer, Global Consulting Detectives (GCD) found three areas that could be improved on to increase Kaizen Hospital’s patient satisfaction. The first area that needs adjustment is the discharge process, where the most time wasted occurred. After researching, we found several studies done on what improvements could be made to the discharge process that would lead to an increase in customer satisfaction. GCD decided to used LEAN methodology to implement a workflow that would eliminate the wasted time. The second area in need of improvement is Kaizen’s cafeteria, where dissatisfaction was specifically related to the temperature of the food. Data suggests that the food temperature plays an important role in patient satisfaction with hospital services. Our recommendation is to use Chinese dim sum carts to keep the temperature warm when food is delivered to the patients. The last area GDC focused on was with employee and staff interactions. Perhaps the most important area within any facility that provides service is the relationship between the employees and customers. The patients at Kaizen hospital feel they are not treated with a positive attitude from the employees based on the documents provided by Kaizen. Our recommendation is to implement an interactive employee training program which includes using visual, hands on, and verbal communication. Throughout the entire implementation process, we are aiming to decrease the discharge process time by 20%, reduce heat lost for food by 60%, and improve employee training programs by involving staff feedback which in turn increases the staff’s level of confidence, teamwork, and communication.

Introduction

This project is helping Kaizen Hospital increase patient satisfaction by improving the process flows of the departments that patients are most dissatisfied with. Possible solutions will be recommended to Kaizen Hospital with a focus on re-engineering the processes for three of Kaizen Hospital's departments. With the qualitative and quantitative data provided for us by the Hospital’s Patient Satisfaction Survey, we believe that decreasing the time to discharge, decreasing food temperature lost, and implementing a new training program will improve the satisfaction level for the patients. We recommend a LEAN methodology for discharge process, heated dim sum carts for cafeteria services, and shorter more interactive training for the staff.

After researching studies done on improving the discharge process that would lead to an increase in customer satisfaction, GCD used LEAN methodology to implement a workflow that would eliminate the wasted discharge time. Additionally, data suggests that food temperature plays an important role in patient satisfaction with hospital services, so our recommendation is to use Chinese dim sum carts to keep food temperature warm when food is delivered to the patients. Our final recommendation is to implement an interactive employee-training program, which includes using visual, hands on, and verbal communication. By implementing an interactive training program that includes problem solving, role-play, and hands on demonstrations, better-trained employees are more equipped to deal with patients.

About Kaizen

Kaizen is the first gastroenterology hospital in Gujarat, and is centered on the idea that every area of life deserves to be continually improved. Their vision of themselves in the future is to be a hospital that is globally recognized for providing superior care and compassion. They hope to attain their goal through meeting patient satisfaction expectations and continuous innovation.

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Business Goals and Objectives

The primary goal of the project is to analyze patient satisfaction data, provided by Kaizen Hospital in order to determine the major dissatisfaction of patients and to deliver recommendations to increase patient satisfaction throughout the discharge processes, cafeteria, and admission. Based on our analysis of the data, the recommended solutions will focus primarily on three key areas of Kaizen: Discharge Process, Cafeteria Services, and Staff Behavior. The goals of auditing these three key areas are to increase productivity and efficiency to better the processes involved with patient interaction at Kaizen Hospital. With the specific training we hope to foster more open lines of communication within the staff. Chinese Dim Sum carts will solve the food temperature issue. LEAN methodology will highlight the places in the discharge process that are available for improvement preparing the way for future improvements. Throughout the entire implementation process, we are aiming to decrease the discharge process time by 20%, reduce heat lost for food by 60%, and improve employee training programs by involving staff feedback which in turn increases the staff’s level of confidence, teamwork, and communication.

Project Scope

The main objective of this project will be to identify specific problems and key processes that impact patient satisfaction at Kaizen Hospital. After analyzing data provided, our team will research specific problems Kaizen Hospital is facing. The team will identify three departments, out of eleven, which GCD can fix with the Kaizen philosophy, using $10,000 as our budget. We will start brainstorming on ideas that fits the category with the knowledge from scholarly sources. With the ideas generated, the assigned team members will then refer back to their original sources to come up with the exact solutions. These will then be tested to see whether or not they fit into the theory as well as the budget. The main focus of GCD will be to improve the departments through LEAN methodology implementation, adopting Chinese Dim Sum carts, and training program changing.

Requirement Number

Sub Categories

Requirement Category Source Status

1 Analyze Patient Satisfaction Survey

Data

All Kaizen Completed

1A Group the data by yearly average

All GDC Completed

1B Sum all three years averages per department

All GDC Completed

1C Rank departments by sum from most

problematic to least problematic

All GDC Completed

2 Select main areas to further analyze

All GDC Completed

2A Isolate the top five problematic departments

All GDC Completed

2B Discuss within the All GDC Completed

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group the three departments we

will be focusing on3 Patient Survey All GDC Completed

3A Compile questions based on problem

departments selected

All GDC Completed

3B Analyze responses we receive from the patient survey we

sent

All Kaizen Completed

4 Analyze food preparation and

storing

Cafeteria Services

Patient Survey Completed

4A Ask how it is done Cafeteria Services

Completed

4B Research how it is done elsewhere

Cafeteria Services

Completed

5 Look into Food Delivery Process

Cafeteria Services

Kaizen Completed

5A Ask Nehal Cafeteria Services

GDC Completed

6 Informal Patient Data

All Initial Videoconference

with Nehal

Completed

6A Ask if the information is

recorded. - no it is not

All Videoconference with Nehal

Completed

7 Discharge informational flow

Discharge Department

Kaizen Completed

7A Ask Nehal how information is

passed between departments -

intercom

Completed

7B Determine who is incharge of the

discharge process

Completed

8 Discharge Paperwork Flow

Discharge Department

Kaizen Completed

8A Determine average time to gather

paperwork

Discharge Department

GDC Completed

9 Research best practices in patient

satisfaction

Technology GDC Completed

9A Wait for the Technology GDC Completed

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answers we may/may not

receive from our patient survey and

analyze their responses

10 Research other food catering

services in Gujurat area

Cafeteria Services

GDC Completed

10A Research cafeteria services in U.S.

hospitals to compare with

Kaizen

Cafeteria Services

GDC Completed

11 Look into training programs

Employee Training

GDC Completed

11A Management should set clear goals, activities, and expectations

for their employees

Employee Training

Kaizen Completed

11B Draft/suggest a training program for Kaizen staff

Employee Training

GDC Completed

Lists of tasks/activities completed per week:

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Our deliverables include the following:● Team Contract ● Initial Proposal, Scope ● Project Requirements● Preliminary Presentation ● Recommendations ● Final Proposal● Final Presentation ● Follow-up Patient Survey● Analysis of Provided Patient Satisfaction Survey

Project ConstraintsThe biggest constraint to our project was time, we only had four usable weeks for this project out of a ten week term. While we did manage to maintain our momentum and meet our projected goals for the week there was a lot of emotional upheaval because of the limited time we had to understand the problem.

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Another constraint that compounded our issues with project time was the skill level of the team. We have performed to the best of our abilities, however there were a few knowledge gaps that made going about this project difficult. We had difficulty in reaching the customer for a meeting. We were unable to confirm a time with them until week seven, which was our second to last week of this project. That meeting took three weeks to plan and confirm. Another constraint was the provided budget, due to the $10,00 limit we were unwilling to recommend a technological solution that came with a large price tag. In addition to this we maintained an awareness of the education level of any end users of our recommendation, which also limited our recommendations based on technology. The largest constraint that we maintained throughout our project was a respect for our client’s philosophy, we did not want to recommend anything that would be counter to the philosophy that Kaizen represents.

Project Assumptions• Assume that most of the staff is illiterate, solutions were made with this in mind.• That the discharge process is paper throughout.• The discharge process changes hands between shifts.• The food is served in containers that are 5in wide by 5in long and 3.125in tall and are stacked four high.• That warming or heating elements are not connected to or used in conjunction with the current food carts• We assume nurses are doing all the discharge process (contact departments, gather files), which start next day• Billing department starts at 9am, which slows the discharge process• Evening round starts at 5pm and takes an hour to make the round• Consultants have time to do 2 rounds/ day

Solutions

Discharge Process

Through our analysis of Kaizen Hospital’s current discharge process, the GDC team has identified the top three areas of dissatisfaction experienced by patients during discharge. These areas, (1) Time taken for discharge, (2) Discharge summary provided on time, and (3) Return of medicines, will be the main focus of improvement within the discharge process. Our recommendation for improvement will involve process audits of Kaizen’s current discharge workflow by specifically targeting those three areas stated above.

Kaizen Hospital’s current discharge workflow takes on average two days for completion. In summary, starting on the evening day before discharge, the Medical Officer/Nurse is informed about patient’s discharge. The MO/Nurse then has to prepare discharge summaries that evening and then enter into HIMS. It is not until the following day that the patient is ordered for final discharge and the bulk of the discharge process is completed. Medical records are then double-checked and the pharmacy department will order the return of medicines. Next, the Billing Department will audit the bills and collect payment,

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which results in a discharge authorization slip. It is not until then that the patient can be discharged. Kaizen’s current process is pictured below:

GDC has concluded that the majority of the process hang up is between the evening rounds of discharge confirmation and the processing the next day. By having only one specific time during the day for all patients to be checked for discharge is inefficient. Our proposed solution involves the creation of a Discharge Department within Kaizen to handle all discharge activities and requests throughout the day, starting from 8AM. A supervisor will be hired to head the Discharge Department and staffed with current nurses and consultants. This department is responsible for handling and mediating the discharge summary papers between Doctors/Nurses and the rest of the other departments to ensure those documents are provided on time. In addition, the Billing department will operate an hour earlier, starting from 8AM to better align with the Discharge Department’s hours to handle the evening requests the day prior. The hospital staff will process the return of medicines quicker now that the discharge summary and billing can be confirmed before the medication is taken back.

The recommendation also proposes the implementation of two rounds of discharge checks, instead of the current, one evening round. Currently, Kaizen only has one round of discharge checks by consultants, meaning that all patients have to wait until the end of the day to be cleared for discharge in the afternoon the next day. By implementing two rounds, the first being a discharge check by consultants from 10-11AM, patients who are deemed ready for discharge can leave during the evening. After the first round of checks, from (11AM-1PM) a dedicated staff member (Discharge Dept Supervisor) will handle all

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confirmed discharge requests to make sure patient documentation flows efficiently from doctors, to the billing, and then pharmacy departments. The second round of discharge checks will be performed that evening (5-6PM), which will be processed in the morning by the Discharge Department Head. As stated before, the Discharge and Billing departments will operate at 8AM to ensure that the patient documentation is handled as early as possible so that patients confirmed the evening prior can be discharged by the afternoon. Our recommendation of the discharge workflow is below:

By dedicating a department to solely handle discharge activities and requests, in addition to, implementing two rounds of discharge checks, the amount of patients discharged per day will increase with time taken for the discharge process decreasing. Cost estimations of this implementation include, a hire of a supervisor ($3000USD), with the creation of a hospital department ($1300- Office space, office furniture) and will use the already staffed nurses and consultants at Kaizen.

Employee Interaction

The main objective in improving employee and staff interaction is to ultimately improve upon their interactions amongst patients. Focusing on enhancing the skills of all Kaizen staff members will lead to organizational effectiveness. Rather than addressing training through the way Kaizen is traditionally

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doing right now, which is need based, generalized training which held in 90-minute sessions, our plan is to implement hands on, interactive training which can help improve staff behavior monumentally.

The flowchart attached below features Kaizen’s current method of employee training:

As you can see, Kaizen first (1) identifies whether or not employees need training. Kaizen then (2) determine areas that their employees need improvement in and go into (3) general training shortly after. According to the answers we received from Nehal, Kaizen trains their staff by (4) circulating hard copies of PowerPoints and documents related to policies. A regular training session is roughly 90-minutes long. After training, Kaizen (5) conducts formal reviews and exams in specific training programs. If (6) additional training is required, Kaizen will repeat Step 3, General Training and onward.

Our solution to improving Kaizen’s training method is pictured below:

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In this flowchart, Steps 1 - 3 from the first flowchart are repeated. Beginning in Step 4 is our suggestion to Kaizen to introduce an integrated approach to their training system. Although there are separate training programs for employees in different departments, one way to approach such training is to focus on enhancing the skills of all employees through visual, verbal, and hands on training. Traditionally, Kaizen hands out hard copies of policies and PowerPoints during training which can be mundane and boring. Our suggestion for Kaizen is to implement fewer lecture based and more interactive, hands on training such as role play, problem solving, and showing videos. Demonstrating important policies through role-play for instance is much more efficient because it saves paper and gives employees the opportunity to ask questions if they don’t understand right away. Namely, if a supervisor demonstrates the proper way to segregate waste into the correct waste bins, his/her staff will be able to better remember and ask questions on the spot rather than reading through various documents of policies themselves.

Additionally, because there needs to be a certain amount of staff on the hospital floor at all times, supervisors from every department could delegate a certain number of participants to go to training at one time without affecting the daily routines of their unit. Also, instead of one 90-minute long training session, breaking up training into three parts, three 30-minute long sessions is much more effective because it will give staff a fresh reminder in case they forget anything. Training could be broken up with each session held every four months throughout the year. After employees complete their training, we

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recommend evaluations to focus on “self-reflection” and “personal feedback” in place of formal exams and reviews. Feedback from employees gives them the opportunity to express any complaints and suggestions to their supervisor to be addressed. Studies have shown that self-reflection and feedback helped participants improve their confidence level, communication skills, and teamwork.

Through using a hands on, visual approach to training, Kaizen can enhance their employees’ skills in an interactive way that is less mundane than typical training. One drawback could be the cultural aspect in India of “not asking questions” because employees don’t want their employers to think they don’t understand something. However, this drawback is not significant because encouraging feedback is not about asking questions, but about sharing your own ideas and grievances. Feedback in essence encourages communication between employees and supervisors instead of simply asking questions and receiving answers. By taking an integrated approach to training, Kaizen will successfully enhance the skills of workers in all departments thereby creating a synergy that would contribute to organizational effectiveness and patient satisfaction. Better-trained employees therefore are highly equipped to handle interacting with patients as well.

Cafeteria Solution

The main objective in improving cafeteria services is to improve the customer satisfaction, focusing on improving the temperature of the food. We recommend replacing the trolleys with Chinese Dim Sum Steam carts. This can be purchased online on Peach Suite an hotel, resort, and restaurant supplies and equipment store. This product will help keep the food warm, therefore increasing customer satisfaction.

The flowchart attached below shows Kaizen’s current cafeteria food delivery process

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According to the answers we received from Nehal the dietician provides instructions on how to prepare the food. The food takes around 15 minutes to prepare and cook. Once the food is ready they pack the food which takes around 5 minutes. Once the food is packed, every moment between food preparation and food being served is a moment in which heat temperature is decreasing. Food takes around 20- 30 minutes to reach the patient therefore the food starts cooling down, it is usually ready by 11am. By the time the food reaches the patient the food is cold hence they are unsatisfied.

The flowchart attached below shows GCD’s recommendation for the cafeteria food delivery process.

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Our recommendation for the food delivery process does not start to get implemented until the food packing process. Kaizen being a gastroenterology hospital needs to follow the dieticians instructions to prepare food, therefore we do not want to make any changes to that step in the process. Since the food starts cooling down once it is prepared, we recommend that the food is packed and placed into the Chinese Dim Sum Steam cart. The steam cart will allow the food to be insulated therefore keeping the food temperature high when delivered to the patient. This will make the food more appetizing and will increase the patient satisfaction.

The Chinese Dim Sum Steam cart can be easily purchased online at peachsuit.com for $595.04 plus shipping and tax for each cart. The cart is stainless steel 20”W X 30”L X 34”H and can carry around 24 stacks of containers based on the dimensions of the new cart. We recommend purchasing around six carts, one for each floor. The cart uses sterno cooking fuel, it uses alcohol/ canned heat. The cart is small and has wheels for easy maneuvering. This cart will help keep the food warm and insulated for around three hours therefore they can start preparing the food earlier if desired.

Project TeamTeam Layout:

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Team Roles and Responsiblities: ● Nibbs, Iris - Project Manager

● Assigned parts to team members● Oversaw team on making sure they submit parts on time● Ran through project manager charts and guideline assignments● Completed and submitted progress reports● Finalized and submitted deliverables● Contacted and created meeting times with client, team members, coordination team and

professor● Research general hospital information on Kaizen, India and United States Hospitals

● Narithookil, Aleena - Research Analyst/Communicator● Research of Cafeteria food delivery process,● Helped draft patient survey● Created cafeteria delivery process flowchart● Helped format final PowerPoint presentation● Helped write about cafeteria delivery process and lessons learned

● Ho, Chung Hua (Ed) - Presentation Developer, Quality● Check solution quality of three areas● Presentation organizing, right paper● Further improve solutions, ideas generating, project scope, project overview, assist on all

flowcharts creating, executive summary, survey creation. ● Ng, Devin - Presentation Developer, Quality

● Research of Discharge Process● Project Scope● Overview of Project Goals● Presentation● Development of Discharge Flow Charts● Patient Survey

● Nguyen, Alice - Writer/Editor● Research of Employee Training Programs● Helped format Final PowerPoint presentation● Created Employee Training flowcharts

● Pierson, Rachel - Writer/EditorTeam Communication Statistics● Research of Discharge Processes and solutions, Helped format Final PowerPoint

presentation, Helped format and edit the Final Proposal, and Analysed Raw Patient Satisfaction Survey Data

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Over the course of five weeks we met with our client once during the planning stage. As a team we met a total of eight times with more time being dedicated to the wrap up phase of our project.

Our primary form of communication with our client was through email, a total of 39 were sent over the course of the project. Group me, a text forum, was the team's primary form of communication with emails being used to send files or information that could not be easily communicated through text. The team send a total of 16 emails and 690 texts over the life of the project.

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Lessons Learned

There were several lessons we learned over the course of this project. We learned to identify and build on each other’s strengths and weaknesses. We were able to learn this from assigning each other specific roles. We switched roles around after the first week, specifically switching the role project manager to another team member after realizing that member possessed good leadership skills. Additionally, learning how to maintain communication with the customer despite time zone differences was also challenging initially. We had to keep in mind what time our emails were being sent so that our customer would be awake and available to read them. This hurdle was not as large as learning to follow up with the customer however. When sending emails we learned to condense our questions to make sure that they would be answered. When following up after not receiving responses for several days, we had to take an assertive approach and ask that our questions be answered to move forward with the project efficiently. Lastly, we had to keep in mind the cultural differences when formatting emails as well. Text formatting for dates and listing our names were different (ex: Last Name, First Name) compared to the American way.

Throughout the project our group faced some challenges such as having disagreements on certain topics. We had outspoken members within our group and with the pressure of meeting deadlines it lead to small disputes. For example when we were trying to make a scope change we were debating if we wanted to change the scope to design thinking. Certain days not all group members were able to attend meetings due to prior obligations. We faced this issue by virtually communicating with them or briefing the person individually.

Conclusion

In conclusion, our project with Kaizen put us in a realistic situation for something that we could all apply in the real world. Specifically, analyzing data that Kaizen collected for us was a good starting point in figuring out what departments to focus on. After narrowing down the departments that received the most complaints. Discharge, Cafeteria, and Employee/Staff Interaction, we delved into research for possible solutions to implement to resolve the issues within each of these departments.

Namely, the main area of concern for the Discharge department was the lengthy discharge time. To resolve this issue we plan on hiring a supervisor to oversee all discharge activities. Then we suggest implementing two rounds of discharge checks by consultants instead of the one pre-established round of evening checks. Shortly after patients are discharged, we suggest giving a follow-up call 72 hours after patients are discharged. Next, for the Cafeteria department the main complaint from patients was with food temperature. Our recommendation for this was to purchase six Chinese dim sum steam carts, one for each floor to transport food to. These dim sum carts insulate food and keep them warm after the 15-20 minutes of preparation for the food. Lastly, to improve employee and patient interaction we recommend Kaizen implements a new, interactive training program in place of the current program. The new program suggests involving employee feedback and self-reflection so employees feel more involved. Since many Kaizen labor employees are illiterate, by inputting interactive games and problem solving, these employees won’t have to be concerned with not being able to read hard copies of documents and policies handed to them. Better-trained employees are more equipped to handle their daily transactions with patients.

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Overall, our solutions for the dim sum carts and hiring supervisors will cost $9,600 with the leftover amount of $400 to be used for labor costs from training sessions. Our budget is in line with Kaizen’s budget of $10,000.

Overall, this project gave us a set amount of time to come up with helpful recommendations for Kaizen to improve their patient satisfaction. Improving patient satisfaction brings a good name to the hospital and encourages positive word-of-mouth for Kaizen which can bring in more patients for Kaizen. We hope our solutions are helpful and in line with the Kaizen philosophy of “every aspect of life deserves to be continuously improved.”

Works Cited/Referenced

Deepak, K. K., Kumar, Y., & Adkoli, B. V. (2014). Extending professional education to health workers at grass root level: An experience from all india institute of medical sciences, new delhi. Indian Journal of Community Medicine : Official Publication of Indian Association of Preventive & Social Medicine, 39(1), 38. doi:10.4103/0970-0218.126358 Panchapakesan, P., Sai, L. P., & Rajendran, C. (2015). Customer satisfaction in indian hospitals: Moderators and mediators. The Quality Management Journal, 22(1), 10. Subrahmanian, M. (2010). EVALUATING TRAINING PROGRAMMES IN INDIA POST. Researchers World, 1(1), 81.

Khurana, S., Taneja, N., Thapar, R., Sharma, M., & Malla, N. (2008). Intestinal bacterial and parasitic infections among food handlers in a tertiary care hospital of north india. Tropical Gastroenterology : Official Journal of the Digestive Diseases Foundation, 29(4), 207.

Sonnino, R., & McWilliam, S. (2011). Food waste, catering practices and public procurement: A case study of hospital food systems in wales. Food Policy, 36(6), 823-829. doi:10.1016/j.foodpol.2011.09.003

Lund, B. M., & O'Brien, S. J. (2009). Microbiological safety of food in hospitals and other healthcare settings. Journal of Hospital Infection, 73(2), 109-120. doi:10.1016/j.jhin.2009.05.017

Peachsuite Hotel, Resort & Restaurant Supplies and Equipment. (n.d.). Gsw C-STM Stainless Steel 20"W X 30"L X 34"H Chinese Dim Sum Steam Cart. http://www.peachsuite.com/

Amazon. (n.d.). Rome 2667 Stainless Steel 4-Tier Round Tiffin Food Carrier, 5 by 12.5-Inch. http://www.amazon.com/Udayai, K., & Kumar, P. (2012). Implementing six sigma to improve hospital discharge process. International Journal of Pharmaceutical Sciences and Research, 3(11), 4528-4532.

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Breslin, S. E., Hamilton, K. M., & Paynter, J. (2014). Deployment of lean six sigma in care coordination: An improved discharge process. Professional Case Management, 19(2), 77-83. doi:10.1097/NCM.0000000000000016

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