Transcript Documented Management System

Industrial Engineering in an Unusual
Healthcare Setting
Richard Blackwell
Project Director, Process Quality
Cermak Health Services
November, 2009
Summary
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Brief history of IE and Quality
Background on Cermak Clinic
Describe the problem: distribution and administration of
medications to CCJ detainees
Discuss the approach taken, results to date, and expected
outcomes
Outline other IE projects being considered at Cermak
Discuss the potential impact of IE in healthcare and other
service industry applications
Goals
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Discuss and demonstrate use of several IE techniques
in an unusual healthcare setting
Value Stream Analysis and process mapping
 Six Sigma process improvement (DMAIC)
 Quality Management System support of accreditation audits
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Suggest possible career directions for IE students
Who I Am
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Graduated from U of I with MSIE in 1978
Career trajectory
 Manufacturing and distribution applications of OR/MS techniques
 Owned my own consulting and software development company
 Telecommunications from 1997 to 2009; Project and Product
Management; Marketing; Quality
 Currently Project Director for Process Improvement at the Cermak Clinic
of Cook County Jail
After 30+ years in Industry, I still consider myself an IE;
everything else is just what I happen to be working on
Quality Management Systems - Quick
Background
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Industrial Engineers (as Scientific Managers) basically invented the Quality
discipline – Walter Shewhart, Joseph Juran, W. Edwards Deming
Starting in the 1970s, traditional Quality Control shifted to more comprehensive
Systems approaches
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Good Manufacturing Practice (GMP) driven by the FDA
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International Standards Organization (ISO) Certification
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Malcolm Baldridge Award (Motorola the first winner in 1988)
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Motorola’s Six Sigma methodology
During the 1990s, an expansion of formal QMS Certification into new areas
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Software Engineering Institute’s Capability Maturity Model -> CMMI
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ISO “Variants” (TL 9000, QS 9000, AS 9000, …)
Our Approach
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Starts with Six Sigma as a structured problemsolving approach
 Methods
(e.g. DMAIC)
 Tools: statistical and process/problem analysis
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Uses Quality Management System certification as a
goal and a club to drive organizational change
Cermak Health
Services
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Part of the Cook County, Illinois Health & Hospitals System
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Located in the Cook County Jail
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The largest single-site correctional healthcare facility in the US
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Provides comprehensive care for ~10,000 detainees
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150,000 sq ft in 129 bed infirmary plus satellite facilities within the jail
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Responding to Department of Justice findings from 2008, Cermak is
currently upgrading service delivery capacity and methods
Industrial Engineering in Healthcare
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IEs (as Management Engineers) and other healthcare
professionals have often used IE/OR/MS techniques
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Process simplification and re-engineering
Process automation
Patient safety
Both IIE and ASQ have divisions that focus on healthcare
Opportunities will expand as healthcare cost containment
efforts ramp up
Case Study - Medications
Administration
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20% of detainees receive medication, with many
receiving more than 1
Patients are dispersed
129-bed Infirmary for acute care
 3 step-down intermediate care units
 General population is in 247 small living units (~50 per unit)
in 17 stand-alone Divisions
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A court has determined that detainees are to receive
all prescribed meds within 24 hours of prescription
Complications
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Detainees move around
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Transferred at short notice, or may be in Court or school at
meds admin time
Meds distribution methods vary
Dose by dose administration of TB, HIV, psychotropics, and
controlled substances
 7-day self-packs when appropriate
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Dispensed from central pharmacy and also from meds
rooms in some units
The Project
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Develop a single, documented process that will be
followed for all detainees in the system
Eliminate non-Value Add steps
 Shorten the fulfillment cycle to 24 hours or less
 Reduce/eliminate missed or incorrect meds
 Institute control of drug inventory
 Reduce returns
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New process is the basis for the implementation of a
new campus-wide computer system
The Approach – Six Sigma
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DMAIC process improvement
 Define
the problem
 Measure
the scope of the problem
 Analyze
process data to understand the root causes of the
problem
 Improve
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the system performance
Implement Control system to monitor performance and
prevent re-occurrence of the problem
Define Stage
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Form project team(s) and develop project charter
Map & document current processes
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With groups of stakeholders
By direct observation
Develop a measurement plan
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Anecdotal data from stakeholders not usually sufficient
Six Sigma requires independent data to ensure objectivity
Measurement allows you to develop and pre-test the metrics
employed in the Control plan
A Process (“Swimlane”) Map
Dept
Sub-Process
Operation
Process Logic
Value Stream Analysis
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A more elaborate form of process mapping used in
Lean
 Any
step that does not add customer value is a
candidate for elimination
 Rich vocabulary of symbols for process steps
 Moves
 Delays
 Etc.
 Guides
the development of a desired “Future State”
from the “Current State”
Measure Stage
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Based on Define stage results, Mean Prescription Flow
Time and Delivery Errors per Encounter selected as
targets
In order to meet 24-hour requirement, need to know current
state
 Analysis of Flow Time will support determination of root
causes for delays
 Delivery Errors cause rework, increase mean flow time, and
affect patient safety
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Unfortunately…
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No data is available in current computer systems
Current paperwork inconsistently filled out, results not
tabulated
Measurement plan – limited sampling
Observe meds pass and note results
 Work backwards through pharmacy records to determine
what was prescribed and when
 Analyze monthly nursing records for actual delivery
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Analyze & Improve
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DMAIC is not strictly linear; phases often overlap
In this case, some of the required improvements are
known
 We
can use the data analysis to validate required
process improvements after we start them
 “Surprises” can be leveraged as they occur
Process Results to Date
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Pharmacy capacity is limited by several bottlenecks
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Manual entry of Prescriptions
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Label printing & manual sort
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Staging of meds for delivery to Divisions
Administration in the Divisions contains significant non-Value Added steps
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Redundant manual data transcription
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“Unnecessary” validation of delivered meds against patient’s medical profile
Impossible with current processes to verify that correct meds have been
administered
Improvement approach is to document and implement one standard process
An Implementation Plan
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Present plan to Senior staff
Form Working Group – CQI, Pharmacy, Nursing, Medical
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Draft Context document, review with staff and Software Vendor for accuracy
Combine existing documents and process flows and adapt
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Eliminate non-value adding steps
Leverage Software capabilities
Define and implement metrics support elements in Software
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Review and revise with Senior staff
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Pilot
Review with Dept of Corrections and revise as required
Final approvals
Develop training materials
Train
Monitor & mentor
Why Is Implementation So Hard?
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Most Process Improvement Efforts Fail
 One
study shows that 60% of Six Sigma projects end in
partial or complete failure
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The reasons are not surprising
 People
don’t like to change
 Organizations change all the time, making long-term
committed efforts difficult
 Management commitment is hard to get and keep
 Some projects just don’t make sense
Improving the Odds
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Techniques exist to improve the odds
 Stakeholder
& Force Field analysis: understand the
management setting and risks before starting a project
 Scope Management:
 Avoid
over-commitment and “creep” by clearly documenting
realistic objectives and goals
 Avoid projects lasting > 6 months
 Change
Management: a toolkit for overcoming
resistance to change
The Control Phase
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Implemented using standards-compliant process
documentation
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Includes key elements of a standard Quality Management
System
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Must be supported by senior AND line management
Will face scrutiny by employee unions
A performance measurement system
Internal Audit (Self-monitoring)
Management Review; Corrective/Preventive Actions
Verified by an independent accreditation body (NCCHC)
Continual Management Dynamics
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Management Involvement
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Management is focused on Customer satisfaction,
relationship development and communication
Documented Management System
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Customer
Focus
Management
Involvement
Customer Focus
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Management commitment to all aspects of the
Quality System
Quality
System
Documentation is available that provides policy,
responsibilities and records in accordance with the
Quality System
Internal Audit
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Periodically conducted to verify effectiveness of
Quality System
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Document / communicate audit plan and ensure
independence of auditors
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Reviewed by Management
Improvement Processes
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Monitor, measure and analyze processes for
conformity and improvement to products
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Corrective/Preventive Actions
Improvement
Processes
Internal
Audit
Documented
Management
System
Other IE Projects
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Map & Streamline the sick call process
Map & Streamline the Mental Health care delivery
processes
Design meds administration automation processes
Analyze and optimize layout and throughput of a
proposed detainee admitting facility
Common IE Skills Used
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Process analysis
Statistical analysis of process data
Process design, documentation & implementation
Design of management metrics systems
Support of certification/accreditation
Design & implementation of process automation
Cross-disciplinary team leadership
Career Ideas for New IEs
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Healthcare – it’s exploding
Public Sector – Lord knows they can use us…
Software/Consulting – draw on IE training, & gets you
into the game
Project Management – a natural step up from entrylevel, and there are never enough PMs
Six Sigma – a natural for IEs; you already know most
of this stuff
Lean – IE with a different name
Links and Resources
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www.punshui.com: my slides and other materials
www.lean.org: lots of ideas and resources re Lean methods and
tools
www.asq.org: starting point for Six Sigma and many other
directions in Quality
http://www.iienet2.org/SHS/Community/Default.aspx: IIE Society
for Health Systems
http://www.asq.org/healthcare-use/why-quality/overview.html:
ASQ Healthcare Division
www.pmi.org: professional certification for Project Managers and
lots of tools
Questions?