Outpatient Flow: Lab and ImagingOutpatient Flow: Lab and Imaging

Northwestern Michigan CollegeNorthwestern Michigan CollegeLean Office Champion Project Lean Office Champion Project

October 2014 – March 2015October 2014 – March 2015

Darrell Lavender, MBA Performance ImprovementDarrell Lavender, MBA Performance ImprovementWest Shore Medical CenterWest Shore Medical Center

Project CharterProject Charter

Project: Outpatient Flow: Lab & ImagingProject: Outpatient Flow: Lab & Imaging

Value Stream Manger: Value Stream Manger: Sonja Ganger, Director, Patient AccessSonja Ganger, Director, Patient Access

Team Members: Team Members: – K. Acker, Provider Based ClinicsK. Acker, Provider Based Clinics– C. Young, RegistrationC. Young, Registration– T. Pepera, LabT. Pepera, Lab– K. Erickson, ImagingK. Erickson, Imaging– S. Ganger, Patient AccessS. Ganger, Patient Access– K. Balzuweit, LabK. Balzuweit, Lab– J. Brand, ImagingJ. Brand, Imaging– D. Lavender, Performance Improvement D. Lavender, Performance Improvement

Purpose: Improve WSMC’s outpatient experience by Purpose: Improve WSMC’s outpatient experience by improving the patient flow for lab and imaging. improving the patient flow for lab and imaging.

Project Charter ContinuedProject Charter Continued Metrics for Registration/Lab/Imaging include: Metrics for Registration/Lab/Imaging include:

– Patient Experience Percentile Rank (outcome)Patient Experience Percentile Rank (outcome)– Patient Experience top box percentages (outcome)Patient Experience top box percentages (outcome)– Patient Experience negative comments about this process (outcome)Patient Experience negative comments about this process (outcome)– Waiting times (process)Waiting times (process)– Documentation missing/incomplete rates (process)Documentation missing/incomplete rates (process)– Rework rates/times (process)Rework rates/times (process)

Scope: Scope: PBC order process patient completes test at HospitalPBC order process patient completes test at Hospital

Parameters:Parameters:– RegulationRegulation– PayersPayers– TJCTJC– FacilityFacility– StaffingStaffing

Project Charter ContinuedProject Charter Continued

Deliverables: Deliverables: – Current state value stream mapCurrent state value stream map– List of opportunitiesList of opportunities– Prioritization of opportunitiesPrioritization of opportunities– Analysis of key opportunitiesAnalysis of key opportunities– Future state value stream mapFuture state value stream map– Implementation plan for key opportunitiesImplementation plan for key opportunities– Improve efficiencyImprove efficiency– Improve satisfactionImprove satisfaction

Timeline: Timeline: – Complete entire planning by February, 2015. Complete entire planning by February, 2015. March!March!

– Implementation begins April/MayImplementation begins April/May– Project completes by June. Project completes by June. Start another round?!?!Start another round?!?!

BackgroundBackgroundMarket share and access are strategically vital. There Market share and access are strategically vital. There are multiple processes which are highly variable and are multiple processes which are highly variable and fraught with waste, delays, and rework. These result in fraught with waste, delays, and rework. These result in poor experiences for outpatients. Quality, safety, poor experiences for outpatients. Quality, safety, customer experience, and finances are directly impacted customer experience, and finances are directly impacted by this value stream.by this value stream.

BackgroundBackground

Laboratory Imaging

Going to the GembaGoing to the Gemba

Going to the GembaGoing to the Gemba

Going to the GembaGoing to the Gemba

xxGoing to the GembaGoing to the Gemba

Going to the GembaGoing to the Gemba

Going to the GembaGoing to the Gemba

Going to the GembaGoing to the Gemba

Going to the GembaGoing to the Gemba

Value Stream Map: Current StateValue Stream Map: Current State

Once the Provider and/or Clinical Coordinator at the PBC launch the order(s), our patients were subject to 1 or more of 3 primary tracts: Pre Op, Pre Reg, Unscheduled

Value Stream Map: Current State Value Stream Map: Current State Drilldown: Unscheduled LabDrilldown: Unscheduled Lab

Some steps not value added but necessary; some steps not value added

1-10

Mean:

23.5 minutes

Range:

9-131 minutes

Sample n=

Reg:792 Lab:546

0.5 4 7

3-190-49

5

2-421-2

2

01-7

01-2

4 1

Cycle Time: 7-122

Wait Time: 2-9

Lead Time: 9-131

Value Stream Map: Current StateValue Stream Map: Current State creating flow & problem solvingcreating flow & problem solving

Value Stream Map: Current State Value Stream Map: Current State Drilldown: PBCDrilldown: PBC

Current Condition:

Value Stream Map: Current State Value Stream Map: Current State Drilldown: PBCDrilldown: PBC

Root Cause Analysis for not having more lab draws at the primary care office location

Only 2 certified phlebotomists

Competencies needed

Others capable; trained/untrained

Location/space logistic issues for office and patient

Phlebotomist notificationProvider awarenessLab equipment limitations

Need more lab equipment

EQUIPMENT PROCESSMANAGEMENT

PEOPLE MATERIAL MEASUREMENT

BARRIERS TO LAB DRAWS

Value Stream Map: Current State Value Stream Map: Current State Drilldown: PBCDrilldown: PBC

Counter Counter measuremeasure

Effectiveness Effectiveness (1-5)(1-5)

Feasibility Feasibility (1-5)(1-5)

ScoreScore

competency check competency check offoff

55 55 2525

train more peopletrain more people 55 55 2525

address space address space (centralized vs. (centralized vs. decentralize)decentralize)

44 22 88

educate providerseducate providers 55 55 2525

get more lab get more lab equipmentequipment

44 44 1616

Counter measures: Standardized

work and

leveling

Value Stream Map: Current State Value Stream Map: Current State Drilldown: RegistrationDrilldown: Registration

Wait Time – Wait Time – Record name in Record name in

lobby to complete lobby to complete reg processreg process

MinutesMinutes

Complete and Complete and accurateaccurate

When issues are When issues are identified with identified with

orders – percent orders – percent resolvedresolved

Time spent in reg Time spent in reg dealing with dealing with

documentation documentation issuesissues

MinutesMinutes

n=792n=792

Mean = 9Mean = 9

Range = 1-52Range = 1-52

85%85% 80%80% n=37/66n=37/66

Mean = 24/16Mean = 24/16

Range = 5-60/2-50Range = 5-60/2-50

Current Condition:

Value Stream Map: Current State Value Stream Map: Current State Drilldown: RegistrationDrilldown: Registration

Problem Tree:

Incomplete/missing orders/doc

for lab/imaging

Technology investigation

Variation in office

practiceNot tested ahead

STAT testing / scheduled

missed authorizations

Missing fax

Patient walk in from

Doctor’s office

Imaging needed pre-auth

Dx code incorrect

(ABN)

All 7 criteria not met

Greater wait time

Staff re workPatient has to

come back

Standardized work

and visual

management

Value Stream Map: Current State Value Stream Map: Current State Drilldown: ImagingDrilldown: Imaging

Current Condition:

Value Stream Map: Current State Value Stream Map: Current State Drilldown: ImagingDrilldown: Imaging

Current Condition:Imaging Volume Analysis3/16/2015Katie, Kathy, Jim, Darrell

Imaging Volume: March 9-13, 2015

Total tests Scheduled Add onsCancel / no show

Lab draws for PT, PTT,

Bun/cre

missing papers

CT 72 37 37 2 16 1

US 88 71 20 3 4

MRI 35 35 3 3 8

Nuc 8 6 3 1

Mammo 49 51 1 3

Xray 205 10 195 1

Dexa 10 11 1

OR calls 5 5 0

total: 472 221 264 13 24 6

percent: 100% 47% 56% 3% 5% 1%

note: numbers may not be exact but margin of error is small

Leveling and

pull process

Value Stream Map: Current State Value Stream Map: Current State Drilldown: LabDrilldown: Lab

Current Condition:

Value Stream Map: Current State Value Stream Map: Current State Drilldown: LabDrilldown: Lab

Leveling and

pull process

Current Condition:

Existing Visual ManagementExisting Visual Management

5S Opportunities5S Opportunities

Especially for pre-visit order management

First Up A3sFirst Up A3s

PBC – Increase lab draws at Primary Care PBC – Increase lab draws at Primary Care

Registration – Improve pre visit order management Registration – Improve pre visit order management

Lab – Improve process for lab draws in imaging Lab – Improve process for lab draws in imaging & Improve lab coverage and patient & Improve lab coverage and patient intake processesintake processes

Imaging – Improve pre visit order management Imaging – Improve pre visit order management & Improve scheduling process & Improve scheduling process

Final ThoughtsFinal Thoughts

WSMC has used the PDCA model for over 4 yearsWSMC has used the PDCA model for over 4 years

Historically a performance improvement focus; now adding LeanHistorically a performance improvement focus; now adding Lean

Healthcare rich for improvement opportunitiesHealthcare rich for improvement opportunities

Complicated processes to consider; can be over whelmingComplicated processes to consider; can be over whelming

Lean offers a methodical approach, valuable tools, and efficient use of Lean offers a methodical approach, valuable tools, and efficient use of resources to improve process and outcomesresources to improve process and outcomes

Beneficial to analyze flow and list problems from neutral participantsBeneficial to analyze flow and list problems from neutral participants

Team consists of line staff and leadership with appropriate mixTeam consists of line staff and leadership with appropriate mix

Team is making progress and leadership is anxious for resultsTeam is making progress and leadership is anxious for results

WSMC leadership brain stormed broken processes and prioritized listWSMC leadership brain stormed broken processes and prioritized list

QuestionsQuestions