use of kaizen in the re-design of an emergency department

Use of Kaizen in the Re-design of an Emergency Department

WCBF 10th Annual Lean Six Sigma and Process Improvement in Healthcare

Summit

Presented by: Greg Horner, Operational Excellence Leader

Loyola University Health SystemMaywood, IL

• Loyola is a nationally recognized leader in providing health care and in conducting groundbreaking research to treat heart disease, cancer, organ transplantation and neurological disorders.

• Loyola University Medical Center (LUMC) is the core of Loyola and one of the nation’s leading academic medical centers.

Loyola University Medical Center is a teaching, tertiary-care, 570 licensed-bed

facility that includes a Level 1 trauma center and a Burn Center.

A Sense of Urgency

• Change in the world economy– Recession/depression with collapse of mortgage industry

and stock market• Change in state finances

– Arrest and indictment of state governor– Threat of financial insolvency of the State of Illinois

• Institutional “financial challenge” – Decrease in patient volumes– Increase in “state insured patients” in a state where we

were not receiving payment– Health Care reform

Lean Transformation• A change in thinking

– Individual optimization to process optimization– Questioning “what we’ve always done”– Considering improvement as part of our daily job

• A change in behavior– Defining the critical few metrics and opportunities– Measuring performance at all levels

Phases of a Transformation

N/10 pace and 1–3% dedicated to Continuous Improvement

ChangingActions

Imp

ro

vem

en

ts i

n H

D,

Q,

C, D

Introduction Year 1-2

IntenseYear 3-5

Development Year 5 - 10

ChangingHabits

ChangingValues

Understanding &

EmbeddingPrinciples

Kaizen“How We Do It”

Kaizen Event WeekDay 1 Day 5Day 4Day 3Day 2

Tool Specific Training

Observe & Analyze Current Process / Begin Improvements

Continued Improvements

Refinement And Finalize

Improvements Final Presentation

Leader Meeting

Leader Meeting

Leader Meeting

For Quality Improvement Purposes

Areas of Work……..Creating Flow

• Education & Training• Patient Flow

– Identify access points– Elimination of Waiting – Establish discharge processes

• Supply Chain – Product movement

• Care Coordination– Ambulatory– Inpatient

Through a series of Kaizen Events

In the GI Lab• Increased capacity by 70%• Cost avoidance: $13m

expansion• How:

– Value Stream Mapping– Roadmap of events– 5S/Std Work– TPI– MDI

In Supply Chain• Implemented pull systems• Cost reduction: $14m

• How:– Value Stream Mapping– Roadmap of events– 5S/Std Work– TPI– MDI

Kaizen to support the OR

7 Flow Lines Setup Feeding the SterilizersDisciplined Execution

Numeric Driven Preference CardsFemur Facture

Numeric Alias Numeric Alias Numeric Alias

Femur FactureSvc Line Level

Preference Card

MD Customization

Table Positioning Implants

Carmen/Jon

Before 20-30 Trays

After12-16Trays

Emergency DepartmentRe-design

Building the bridge while we walk on it

“A Burning Platform”• Level I Trauma Center• 142 patients a day• 29 treatment bays• 6 hour average cycle time• Increase in “Care Accelerated”• Change in Senior Management Team• Financial challenge to the Medical Center• Workforce reduction program• Physician foundation joins medical center• Vacant ED manager position• Loss of geography for the ED

Mark Cichon, DOED Medical Director

An Opportunity

• Generous Donor• Make a visible difference• Improve patient experience• Improve staff experience• Implement lean

“Let’s do something different…”Deborah Kull

System Director, Operational Excellence

Engagement

• Administration• ED Leadership• Operational Excellence• Next Level Partners• Pratt Design• Walsh Construction• Operations

What is 3P?• A method for designing facility layouts that better meet

Patient and Caregiver needs with improved Safety, Quality, Delivery and at Lower Total Cost

• A rapid cycle process that focuses on generating lots of ideas; with simultaneous input from all stake holders up front for the layout of the Emergency Department

• A method to prioritize and rank the outcomes (layouts) relative to each other

• Trystorming and mockups of the preferred solutions

Madhu

“Executive leadership is critical to success of the process”

Jason KeelerVP of Healthcare Operations

Lessons LearnedExecutive Leadership

Voice of the Customer

Customers: Patients, Patient families, Staff, External Resources (e.g. Ambulance)

Sources:AvatarDept SurveysStaff InterviewsGemba Walks

Group Issue Customer Type Occurrence Weight (1-5)Pt experience Lack of signage Pt 5Pt experience Walk in Entry allows cold/hot air into the reception area Pt, Sec, Reg, RN 5Pt Experience Long wait time for bed assignments Pt, RN, MD 4Pt experience Triage and waiting area looks old and dirty Pt 4Pt experience Lack of Triage Flow Pt, RN, MD 3Staff Experience Desk positioning and layout in ED RN, MD 5Staff Experience Computers are not located near ED patient bay. Staff has back to pt Pt, RN, MD 5Staff Experience Computers not located near ED peds bay. Staff is out of pt room Pt, RN, MD 5Staff Experience Security desk location draws people at walk in entry Sec, Pt 3Staff Experience Resources and supplies are not located in area of need RN, MD 3

Tranlated Customer RequirementI want a clean treatment areaI want a clean waiting areaI want a comfortable waiting areaI want a effi cient charge capture and billingI want a safe environmentI want an effi cient environment of careI want care with minimal waitingI want computer access near the patient and ability to maintain pt visibilityI want effective EMS communicationI want equipment and supplies at POU when I need them I want timely test resultsI want to move the ED patient to a bed in another unit

12 Ideas

• Separated Into 2 Teams with all Functions; Architects, Construction, Clinical, Facilities, Security, Admin

• Each Team Generated 6 Layout Ideas• Each Team Evaluated & Ranked Each Layout per the Criteria

12 Ideas to Top 3

• Teams Presented Each of the 12 Ideas• Entire Team Evaluated then Ranked to

Determine the Top 3 Layout Ideas• Similar Ideas Were Consolidated to Final 2

Layouts

Trystorming

• Constructed the Current State ED• Built a Full Size Half Scale Mock-Up of Layouts• Walked the RN, MD & Patient Flows for

Current State and New Layouts• Generated Spaghetti Diagrams of Each Acuity

Level of the New Layout

Layout

“Bend over: This is going to hurt”Carol Schleffendorf, RN ED Director of Nursing

Lessons LearnedIt is a Painful Process

Detailed Design - Trauma• Teams presented each of

the 10 ideas• Entire team evaluated

then ranked to determine the top layout ideas

• Similar ideas were consolidated to a final layout

Gaming

Design

Consolidate

Ready to Trystorm

Trystorming in a full scale mock-up

“No Problem is a problem”Sharon O’Keefe

President

Lessons Learned:Surface Problems

Detailed Design – Staff & Support

Detailed Design – Patient Bays

Kiosk

Greeter

Triage

ED Bay

Designed Layout

ResultsCategory Baseline Layout 1 % ChangePatient TravelES 1 & 2 700 638 8.9%ES 3 & 4 & 5 1652 370 77.6%Trauma 268 240 10.4%

Nurse TravelES 1 & 2 1325 898 32.2%ES 3 & 4 1876 210 88.8%Trauma 483 282 41.6%

Physician TravelES 1 & 2 215 132 38.6%ES 3 & 4 375 24 93.6%Trauma 200 96 52.0%

Totals 7094 2890 59.3%

Nurse 3684 1390 62.3%

Results Matrix

Michelle

“No additional rooms???Are you Nuts?”

ED Staff

Lessons Learned:Flow Builds Trust

Acuity TotalsAvg per

Day Area Beds Turns CapacityAvg Daily Demand*

Daily Utilization

1 112 12 1748 193 3928 444 2421 275 155 27 28 08 87 1

8479 94 29 16 98 94



Daily Utilization

1 112 12 1748 193 3928 444 2421 275 155 27 28 08 87 1

8479 94 29 16 107 94



Daily Utilization

1 112 12 1748 193 3928 444 2421 275 155 27 28 08 87 1

8479 94 29 21 136 94

* ESI 4,5 and 1/3 of ESI 3 in Quick Care

90%

22 2 44 50* ESI 1,2 and 2/3 of ESI 3 are in these

beds

4 12 48 43 * ESI 4,5 and 1/3 of ESI 3 in Quick Care

90%

Peak Period Analysis - 12 Hours 10:00 AM to 9:00 PM

22 2.4 52.8 50* ESI 1,2 and 2/3 of ESI 3 are in these

beds

94%

3 2 6 1 21%

113%

4 12 48 43

66 50* ESI 1,2 and 2/3 of ESI 3 are in these

beds

75%

3 2 6 1 21%

ED

Quick Care

Trauma

ED

Quick Care

Trauma

ED

Quick Care

Trauma

3 2 6 1 21%

4 16 64 43 * ESI 4,5 and 1/3 of ESI 3 in Quick Care

67%

22 3

Impact of Flow – Peak Hours

“Respect your extended network of partners”

Jeffery K. LikerThe Toyota Way

Lessons Learned:Include the Vendors

Concerns

Questions?

Speaker BioGreg Horner is an Operational Excellence Leader at Loyola University Medical Center where he is leading transformational change and utilizing lean principles to improve the staff and patient experience.

Greg is an ASQ certified Six Sigma Black Belt and a student of the Toyota Production System (Lean). He has studied TPS under a 1st generation Sensei from Toyota including the proper use of 3P and standard work.

Greg is a certified systems engineer, database administrator and is currently earning a master’s degree in Enterprise Improvement and Innovation from DePaul University in Chicago.