Long Stay Patient Workshop
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Long Stay Patient Workshop October 2010. Michael Blatchford, Consultant Health Roundtable. Sometime work feels like this. This Sessions Objectives. How Lean Principles can be used to rescue the Stranded Patient How to selecting the right patient type How to conduct a Waste Audit

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Michael Blatchford, Consultant Health Roundtable

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Michael blatchford consultant health roundtable

Long Stay Patient Workshop

October 2010

Michael Blatchford, Consultant Health Roundtable


Sometime work feels like this

Sometime work feels like this


This sessions objectives

This Sessions Objectives

How Lean Principles can be used to rescue the Stranded Patient

How to selecting the right patient type

How to conduct a Waste Audit

How to measure the Stranded Patient

How to use Practical Problem Solving

How to use Value Stream Mapping


Warning parts of this presentation are like a keystone bridge

Warning – parts of this presentation are like a Keystone Bridge


Current state

Current State


Michael blatchford consultant health roundtable

Lean Thinking Framework for Long Stay Patients

Workshop One (2 days):

1.1Intro & Eight Wastes and Long Stay Registry

1.2 Aims & Measures

1.3 – 1.4 Value Stream Mapping

2.1 VSM – People Engagement

2.2 VSM Validation & Pt Story

2.3 5S

2.4 Planning 

Workshop Two (2 Days):

3.1 Report Back

3.2 Problem Solving

3.3 – 3.4 Push Pull Simulations

4.1 Future State Map

4.2 Leveling and Queue Reduction

4.3 People Engagement

4.4 Action Planning

Weekly 20 Minute Teleconferences

Workshop Three (2 days):  

5.1 Report Back

5.2 Visual Workplace

5.3-5.4 Standard Work

6.1 Mistake Proofing & Quick Changeovers

6.2 & 6.3 Sustainability

6.4 Action Planning

Sustained change


Select aim statement

Select Aim Statement

Within 6 months, the nos. of acute # NOF patients with an average LOS >21 days will decrease by 50%.

100% of stroke patients will have a length of stay less than 21 dayswithin 6 months.

To reduce palliative care patients with LOS above 30 days to 0 overa six month period.

By May 2011, we will ensure no craniotomy patient remains as an inpatient beyond 21 days unless their neurosurgical condition dictates this.

To reduce the hospital length of stay of the colorectal stranded patient by 30% over three months.


Waste audit

Waste Audit

Waiting

Overproduction

Rejects

Motion

Processing

Inventory

Transport

Staff Utilisation


Exercise 1 waste audit

Exercise 1: Waste Audit

Write the Number for the waste

Write the Letter for the waste

Write the estimated time lost on the waste

Write the identified waste as a question


Michael blatchford consultant health roundtable

Waiting

Understanding Waste

For people, signatures, and/or information is waste. This is “low hanging fruit” which is easy to reach and ripe for the taking.

  • Waiting in ED to be seen, waiting to be admitted

  • Excessive signatures or approvals

  • Dependency on others to complete tasks

  • Delays for test results

Waiting - delays for PEGS, CT scan, echocardiograms, angiograms, families to make decisions/consent/meet, ACAT team, Limited weekend services


Understanding waste

Understanding Waste

Overproduction

Producing work prior to it being required is waste and is the greatest of all the wastes

  • Meds given early to suit staff schedule

  • Testing early to suit lab schedule

  • Producing reports no one needs or reads

  • Batch processing – scripts, referrals, pharmacy protein drinks

Overproduction- rehab & ACAT assessment too early


Understanding waste1

Understanding Waste

Rejects

An adverse event with serious consequences occurs in about 15% of overnight stays (Jackson, Duckett et al 2006, J Health Serv Research 11:21-6)

Refers to all processing required creating a defect or mistake and the additional work required to correct it

  • Adverse Events (sentinel events, medication errors) –

  • Wrong or missing patient information

  • Forwarding partial documentation to the next process

  • Lost files or records

  • “only 10% of the time is everything right when we go to theatre”

Rejects – falls & assoc injuries, NGT dislodgement & replacement assoc Xrays, nosocomial infection,


Understanding waste2

Understanding Waste

Motion

Any movement of people, paper, and/or electronic exchanges that does not add value is waste

  • Searching for patients

  • Searching for work documents

  • Searching for medications

  • Searching for computer files on your desktop

  • Hand-carrying paper work to another process

  • Searching for poorly located supplies

  • Walking to equipment that is not centrally located

Cost of orderly to transfer & nurse to escort – taking nurse away from other allocated patients


A sad error

A Sad Error

Understanding Waste


Michael blatchford consultant health roundtable

Understanding Waste


Michael blatchford consultant health roundtable

Understanding Waste

More Motion Waste


Understanding waste3

Understanding Waste

Processing

Putting more work or effort into the work required by internal or external customers is waste or doing the steps in the wrong order

  • Duplicating tests, reports or information – 25 Funct. Asx

  • Ordering more diagnostic tests than the diagnosis warrants

  • Completing excessive paperwork – Obstetric Theatre 5 copies

  • Entering repetitive data / information – Multiple Demographic Histories

Processing- new assessments by rehab allied health staff when acute staff have done same, completion of multiple referral forms with same information, No single CVA AH team from admission to d/c [ED/Acute/rehab]


P rocessing

Processing

Understanding Waste


Understanding waste4

Understanding Waste

Inventory

Work piles, excessive supplies, and excessive signature requirements are waste

  • Duplicate medications and supplies in excess of normal usage – 15K excess dialysis fluid

  • Files awaiting tasks completion or approval by others

  • Extra or out-dated manuals, newsletters or magazines

  • Purchasing excessive office supplies

  • Obsolete files, and equipment

  • Insufficient cross-training of staff


Understanding waste5

Understanding Waste

Transport

The extra or unneeded time element associated with the delivery of work to a process

Patient visits 15 locations in 1 antenatal visit!

  • Transporting patients to surgery prematurely or unnecessarily moving them around

  • Moving samples, specimens, documents, equipment early /late or to the wrong location

  • Delivering documents that are not required

  • Excessive filing of work documents

Transport- moving between several wards, to & from Radiology


Understanding waste6

Understanding Waste

Staff Utilisation

Is a result of not placing people where they can (and will) use their knowledge, skills, and abilities to the fullest

  • Not using staff ideas – move the in tray

  • Not maximizing staff time on core tasks

  • Project deadlines not being met

  • High absenteeism and turnover

  • Inadequate performance management system

  • Incomplete job skill assessment prior to hiring


Aha moments

AHA Moments

Heavenly Mail box

Consolidation of paper work

Cluttered workspace

Dedicated staff area

Multiple spots of linen storage

Sensitive literature relocated

“That is hideous”


8 wastes

8 Wastes


Benefit vs effort

Benefit Vs Effort


Daily measurement

Daily Measurement


Issues log

Issues Log


Issues log1

Issues Log


Practical problem solving

Practical Problem Solving


Michael blatchford consultant health roundtable

The Health Roundtable

A3 PRACTICAL PROBLEM SOLVING ( PPS )

TEAM MEMBERS

DEPARMENT / AREA

DATE

PROBLEM DEFINITION

FISHBONE ANALYSIS

TOP 3

MAN

MACHINE

METHOD

WHAT –

STANDARD –

WHERE –

WHEN –

EXTENT -

1

2

3

MATERIAL

MEASUREMENT

ENVIRONMENT

5 WHY ANALYSIS TOP 3

WHY –

BECAUSE –

WHY –

BECAUSE –

WHY –

BECAUSE –

WHY –

BECAUSE –

WHY –

BECAUSE –

WHY –

BECAUSE –

WHY –

BECAUSE –

WHY –

BECAUSE –

WHY –

BECAUSE –

WHY –

BECAUSE –

WHY –

BECAUSE –

WHY –

BECAUSE –

WHY –

BECAUSE –

WHY –

BECAUSE –

WHY –

BECAUSE –

POINT OF CAUSE

PROBABLE CAUSE -

COUNTERMEASURE ACTIVITY

CONTAINMENT ACTIVITY

ACTIVITY

CHECK PERIOD

DATE

ACTIVITY

CHECK PERIOD

DATE

WHO

WHO

PART

DAY

WK

PART

DAY

WK

ROOT CAUSE -


Cause and effect diagram

Cause and Effect Diagram

  • Identify the problem on the right hand side

  • Brainstorm the potential causes of the problem on the left hand side

  • Evaluate each cause – frequency, severity


Results from fishbone exercise those item highlighted in red are the quick wins already achieved

Results from fishbone exercise – those item highlighted in red are the quick wins already achieved.


5 whys

5 Whys


Exercise 2 practical problem solving

Exercise 2 – Practical Problem Solving

Using the A3 Practical Problem Solving handout, fill in for your DHB Long Stay Patients


Value stream map current state

Value Stream Map – current state


Michael blatchford consultant health roundtable

Value Stream Map – current state

THE 7 STEPS

Identify the Value Stream (“patient perspective”) and

collect Patient and Staff Stories (“Bubbles”)

Identify Process Steps in the Journey (“Boxes” ) - green

Document Key Tasks within Each Step - yellow

Estimate Delays and Queues between Steps - red

Show Patient flow

Identify Supporting Flows of Info, Staff & Materials - blue

Estimate Total Value Added and Wasted Time


Michael blatchford consultant health roundtable

Value Stream Map – current state


Value stream map walkthrough

Value Stream Map Walkthrough

Lots of paper work shuffling from GP to admission.

Where does the patient and carer fit in?

There is a well defined process up to day 8 to 10

Where does the MDT fit in?

Surgery happens on a Monday but best case LOS is Tuesday, so where to they go when the inn is full?

We move patients out of 3E on day 6, and this is where issues may arise, no plan, unfamiliar patient and procedure, outlier issues.

From day 10 on reduced planning, all related to symptom control, are we trying to fit a square peg into a round hole?.


Value stream map future state

Value Stream Map – Future State

1) Elective day surgery and OT

2) Elective day surgery and OT combined

3) Emergency and OT


Value stream map future state1

1. Produce to your Takt time

2. Develop one piece flow wherever possible

3. Use pull and kanbans to control the process if one piece flow does not exist upstream

4. Try to send the patient schedule to only one process step (as close to the end as possible)

5. Distribute the treatment of different patients evenly over time at the pacemaker process (start with the greenstream)

6. Create an “initial pull” by releasing and withdrawing small, consistent increments of work at the pacemaker process (to meet system takt time)

7. Develop the ability to handle “every patient need every day” (then every shift, then every hour) in treatment processes upstream of the pacemaker process

Value Stream Map – Future State


Takt time

Takt Time

This synchronizes the flow in the hospital to match the patient demand

Takt time= available working time per day

patient demand per day

Long Stay Stroke Patients

217 patients per year 365/217 = 1 patient every 1.68 days or every 40 hours


Batching vs one piece flow

Batching Vs One Piece Flow

Palliative Care Ward

Weekly 90 minute MDT meeting with 20 staff

Vs

Mon, Wed, Fri 10 minute meeting with 6 staff

Surgical Ward

Weekly Consultant driven discharges

Vs

Daily event driven discharges (Nurse led on weekends)


Push vs pull

Push Vs Pull

Palliative Care Ward

Ward tries to Push patients into aged care facilities

Vs

A Nurse Practitioner, GPs and medical support work with aged care facilities to provide palliative care in the aged acre facility. The aged care facilities now look into ward and pull appropriate patients


Value stream map future state2

Value Stream Map – Future State

1) Elective day surgery and OT

2) Elective day surgery and OT combined

3) Emergency and OT


Proposed key changes

Proposed Key Changes

1) New admission process

Flag potential Stranded Patients

MDT pre admission assessment

EDD allocation

Event driven visual pathway

2) New hospital process

Emergency theatre session slots

Community referral

EDD allocation and evaluation

3) New discharge process and community process

Discharge 2 by 10am

Patient flow whiteboard and MDT daily meeting

Patient updates event driven visual pathway

Community liaison pulls referrals


Quantitative and qualitative outcomes

Quantitative and Qualitative Outcomes


Quantitative and qualitative outcomes1

Quantitative and Qualitative Outcomes


Quantitative outcomes

Quantitative Outcomes


Acute nof patients with los 21 days

Acute # NOF patients with LOS > 21 days


Bop lean team discharge plan

BOP– Lean Team Discharge Plan


Ward patient board and daily mdt meeting

Ward Patient Board and Daily MDT Meeting


Referral process

Referral Process


Culture change and sustaining the improvements

Culture Change and Sustaining the Improvements


Remember to have fun when making your changes

Remember to have fun when making your changes


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