Transcript Karl Palmer Presentation

Process Improvement
Anyone Can Do:
Basic Tools and Concepts
Karl B. Palmer, RN
Rural Quality Program Conference
Washington, D.C.
September 2, 2009
Red Cedar Medical Center
Mayo Health System
•
Located in Menomonie, Wisconsin
Population Served
– Primary Service Area = 40,000
people
– Approximately 1,000 known,
diagnosed diabetics within project
age ranges
– Predominantly Caucasian with a
notable small population of
Southeast Asian (Hmong) and a
very small population of Hispanic
agricultural workers
Outpatient services include
•
Approximately 40 providers, all
employed by the Medical Center
•
Provider-Based Clinic (department
of a 25 bed Critical Access
Hospital)
– Family Practice, Internal Medicine,
Pediatrics, OB/GYN, Podiatry,
Occupational Medicine,
Orthopedics, General Surgery,
Sleep Medicine, Behavioral Health,
and Physical Rehabilitation
System of Care
•One of 12 organizations that make up Mayo Health
System, part of Mayo Clinic
–Mayo Health System is a strongly
collaborative system with monthly
system-level diabetes team phone
meetings representing all 12 sites
–Mayo Health System has an active
Diabetes Expert Team
• represents multiple sites and multiple roles
• Mayo Health System supports local and system-level transparent
sharing of diabetes data
Just a Bit About Me
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Bachelors Degree in Nursing
Pursuing Masters of Science in Nursing and Healthcare Systems Administration
Seven years bedside critical care nursing
Three years Associate Director of Clinic Nursing
– Received training and experience in Six Sigma, LEAN, PDSA methods, team
leadership/project management, emergency preparedness, staff supervision
Quality Nurse Specialist at Red Cedar Medical Center-Mayo Health System
– Outpatient Diabetes, Ambulatory Care Quality, Patient Safety, and LEAN
Nurse Co-Vice Chair of Quality for Mayo Health System
– Project management, System-level Medication Reconciliation Workgroup lead,
Co-lead Quality EMR Integration Team (current focus on building and
implementing Computerized Physician Order Entry and Order Sets), sit on Mayo
Clinic Nursing Quality Committee
Moral of the story: I am no different than most of you…some classes
and coursework, but the majority of my process improvement education
Has been learn by watching and doing.
Red Cedar medical Center Diabetes Progress
10/2006-6/2009
100%
HgbA1C < 6 mos
HgbA1C < 7
90%
Percentage at Target
LDL < 12 mos
LDL < 100
80%
BP < 130/80
On ASA
70%
Tobacco Free
HgbA1C < 6 mos
60%
HgbA1C < 7
LDL < 12 mos
50%
LDL < 100
BP < 130/80
40%
On ASA
Tobacco Free
30%
Date
Tools We Have Used, That You
Can Too!
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Flow chart
5-whys
Inter-relations diagram
Impact wheel
Associative problem solving
PDSA
Matrix
Why are we doing these things?
• The needs of the patient come first. (Mayo Clinic Primary Value)
• To provide ideal care- Exactly what the patient needs,
when they need it, not more, not less, customizable to
the individual patient, at continually lower cost. (Dr. John
Kenagy)
• To provide care that is Safe, Effective, Patient-Centered,
Timely, Efficient, and Equitable. (The Institute of Medicine)
Reality Check…Culture eats process
for breakfast!
Flow Charting
• Why: To better understand the current state of affairs (or
possibly plan future processes)
•
Keep it simple- just visually represent a process
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Follow the Jimmi Hendrix principle - When flow
charting, stay as high as you can as long as you can
(Charles Liedtke, Strategic Improvement Systems, LLC)
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Ideally, you will base your current state flows on observations of the actual
work (Gemba); observation is always more “real” and accurate than meeting
room memories
•
If unable to observe, use multiple experts, and ask several people to create
or validate the process flow. Often there is not one process (which may be
the root cause of your problems).
Comments on Flowcharting
• You can flow
– Work (people, activities)
– Information
– both
• Use to identify value added steps (For the
patient! Remember why we do this stuff!) and
reduce waste to make the process efficient
• Think of how you can create continuous flow,
instead of batch flow.
• Pull vs Push Flow
Simple Visual Flow
Based on the Adaptive Design concepts of Dr. John Kenagy
Basic Formal Flowchart Symbols
Start or End
Activity
Decision or
Question
Document
Activity
Delay
Start or End
Off Page
Connector
An Actual Example
Illness, Injury or
need for care
(v=variation was noted
during this process step)
Pt calls RCMC (V)
Need/Resource
Match (V)
Pt waits for ED
Pt Waits for U/C
Pt Waits for Clinic
Pt roomed
Pt roomed
Pt roomed
Pt waits
Pt waits
Pt waits
Medical Care or
Patient ReTriaged by
Provider (V)
Patient leaves
Medical Care or
Patient ReTriaged by
Provider (V)
Medical Care or
Patient ReTriaged by
Provider (V)
Patient leaves
Patient leaves
The Message:
Don’t Be Afraid of Flowcharting!
JUST DO IT!
5 Whys
• Find the root cause of a problem
– 1st order problem solving = band aid fix,
happens day after day
– 2nd order problem solving = fix the cause,
problem gone for good
• Helps keep you from jumping to
conclusions
• If you need help
asking why 5 times,
find a 5 year old!
Example
Preventive and chronic disease care is missed during visits
Why?
Provider rushed
Why?
Patients are late, disrupting schedule
Why?
Because they come in the wrong entrance
Why?
Because there is no external signage telling them which
door to use
First Order Problem Solving- Tell patients to come earlier
Second Order Problem Solving - Improve external signage.
Patient Leaves from Walk-In Encounter
Why?
Wait is too long
Why?
-Not enough clinic openings
-UC busy
Why?
Why?
-Lack of MD/PA in clinic
-Meetings -Hosp -Sched ule full
Why?
-Too many off
-Done
-see 2b
-see 2c
-Long term absence
Why?
Why?
-No enforced rules
-see 2a
Why?
(2a,
-Rules old
-0 buy in
Why?
-Not reviewed
2b, and 2c are additional 5 why branches)
Why?
-What’s in it for me?
Why?
-No one responsible
Why?
-Value on family time
-Done
Effective solution from this 5 Why-Form a
responsible provider Access Committee to
create and maintain staffing guidelines
Now, we try it with your
Problems!
Inter-relations Diagram
• Helps you sort through and prioritize
multiple causes or issues
• Handy if root cause process like the 5
whys has multiple branches and you are
unsure of where to focus (especially with
limited resources)
• Often based on opinion - If you have solid
data on all items, consider a Pareto chart.
How it works
• Put your issues in a rough circle (Post-its
work well on chart paper)
• Go around the circle of issues one at a
time, and consider direction of impact or
causality (or lack of relationship)
• Represent the direction of causality with
an arrow.
Interrelations Diagram for Preoperative History and
Physical Problems
Chart
Patient
Transcription
Dictation
Routing
Scheduling
Off-Site
The more arrows coming OUT of a category = more likely to be a main driver in
process/problem. (Usually a good “bang for your buck” to start there)
The more arrows going IN to a category may be an ideal place to focus measurement to
show improvement.
Lets Try It
• Financial Problems (High number of uninsured or
underinsured patients, high volume of patient charges written off by
medical center)
• Medication Compliance Problems (Patients not
compliant with filling or taking diabetes medications)
• Lab Compliance Problems (Patients not having
recommended diabetes lab tests in recommended timeframes)
• Visit Compliance Problems (Patients not coming for
diabetes visits)
FINANCIAL
MEDICATIONS
LAB
VISITS
3 Out, 0 In
Primary Driver
FINANCIAL
MEDICATIONS
LAB
1 Out, 2 In
0 Out, 3 In
VISITS
2 Out, 1 In
Impact Wheel
• Use to consider potential consequences of
change.
• Useful to help make decisions when there
is significant risk or resource required to
test a change. Use some caution,
however, as this is completely abstract
thought, not reality. None of us can tell
the future!
• May help you avoid costly (monetary,
cultural, regulatory) mistakes.
How it Works
• Write down the proposed action step in the center
• Write down the expected positive and negative results
of that step around it
• For each result, write down the positive and negative
effects around it
• Continue this process as long as it is helpful
• Color-coding levels of impact may be helpful
Patient
outcomes
improve +
Docs have info to
make clinical
decisions +
Impact Wheel
Budget
Cuts -
Statistics (process
measures )
improve +
Layoffs -
More patients will
Come in for testing +
Revenue
Decreases -
If we stop charging low income patients for lab
tests, then…
Medicare could cite
us for “enticement” -
We could lose
certification -
We could lose
reimbursement -
Lets Try One
• What if your hospital/clinic only offered
vegetarian food choices in the employee
cafeteria?
Staff feel
tired -
Cafeteria unable to
sustain
vegetarian-only
menu
Profit margin for cafeteria
Will decrease -
Cafeteria
revenue
drops -
Less staff
Will eat at work-
If we only offer vegetarian food for staff, then…
Morale will
improve +
Employee obesity levels
will go down +
Employees will feel
healthier +
Less health
insurance claims +
Lower premium
prices over time +
Associative Problem Solving
• Very unique method of getting teams to
think outside of the box
• Can unlock the creativity of employees
How it Works
• Start with the problem
• Have group take 5 minutes, and write
down how they would solve the problem if
they were someone else (you select the
alternate identity)
• After the time is up, go around the group
and capture all unique ideas
• All ideas are okay-impractical, immoral,
illegal, etc.
Problem: patients not coming in for recommended
diabetes visits
• How would Oprah solve this?
• How would a 5 year old solve this?
• How would a pro football player solve this?
Patients not coming in for recommended diabetes visits:
What would Oprah do?
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Send a limo
Build a clinic closer to the patient’s house
Send a doctor to the patient’s house
Do Oprah’s book club on a diabetes book
so that millions of women read it and
realize the importance of visits
Far fetched?
Patients not coming in for recommended diabetes visits:
What would Oprah do?
• Send a limo (offer taxi vouchers)
• Build a clinic closer to the patient’s house
• Send a doctor to the patient’s house (outreach
activities, partner with public health or nursing
schools)
• Do Oprah’s book club on a diabetes book so that
millions of women read it and realize the
importance of visits (do a community diabetes
book club, have an influential community
member campaign for diabetes health)
Patients not coming in for recommended diabetes visits:
What would a 5 year old do?
• Call his friend’s mom to see why he wasn’t
coming over
• Get some new toys so his friend would
come play
• Throw a party
• Be extra nice
• Have hold his friend’s hand on the way
over
Patients not coming in for recommended diabetes visits:
What would a 5 year old do?
• Call his friend’s mom to see why he wasn’t
coming over (call patients)
• Get some new toys so his friend would come
play (add an attraction that will draw people to
your facility)
• Throw a party (hold a special event with a giveaway)
• Be extra nice
• Have hold his friend’s hand on the way over
(facilitate the formation of community buddies)
Patients not coming in for recommended diabetes visits:
What would a pro football player do?
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Get the whole team to help
Take the patient to “training camp”
Assign a special coach to the patient
Hire a trainer to motivate the patient
Waffle over whether or not you will have
diabetes this year or if you will stay glucose
intolerant for another year.
Patients not coming in for recommended diabetes visits:
What would a pro football player do?
• Get the whole team to help (partner with others
like nurse educators, etc to contact and
intervene with the patient)
• Take the patient to “training camp” (take full
advantage of those times when the patient does
come in-arrange doc, dietician, education in one
day)
• Assign a special coach to the patient (case
management)
• Hire a trainer to motivate the patient (in home
visits from a support group member)
One PDSA (Plan Do Study Act)
Tool I Like
• Can serve as “minutes” for rapid PDSA
cycles that occur with hallway huddles as
opposed to real meetings
• Mini-project plan
Worksheet For Testing Change
Aim:
Every goal will require multiple smaller tests of change
Describe your first (or next) test of change: getting the protocol on
the chart
Person
Responsible
When to
be done
Where to
be done
Person
Responsible
When to
be done
.
Where to
be done
Plan
List the tasks needed to set up this test of change
Predict what will happen when the test is carried out
Measures to determine if prediction succeeds
Do
Describe what actually happened when you ran the test
Study
Describe the measured results and how they compared to the predictions
Act
Describe what modifications to the plan will be made for the next cycle from what you learned
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Plan-Do-Study-Act+%28PDSA%29+Worksheet.htm
Available if you have an IHI login and is Free
Matrices
• Keep you organized
• Visual, dashboard type way to
communicate status of interventions
Active Local Team
al
l
m
w
Characteristics
Tool(s) Available
El
Element
Element 1
oo
d
G
le
nw
oo
M
en d C
om
ity
on
O
ve
ie
r
Red Cedar Diabetes Improvement Implementation Matrix
June, 2007
1.1 MD Champion
Role description
1.2 Coordinator
Role description
1.3 Regular Meetings
Proven Practices
1.4 Collaborative Networks
Proven Practices
1.5 Patient Representative
Voice - Customer Manual
2.1 Patients Enrolled
Diabetes Registry
2.2 Staff Trained
Registry Training Manual
2.3 Used for visits
Proven Practices
2.4 Hot Lists Reviewed
Proven Practices
3.1 Standing Orders Approved
Standard Lab Orders
3.2 Standing Orders Utilized
Proven Practices
3.3 Previsit reminders
Proven Practices
4.1 Performance Data Compiled
Registry Data
4.2 Data Displayed with Provider Team Names
Report Template
Element 2
Use Diabetes Registry
Element 3
Automate Care
Element 4
Performance Review - Transparency
S
=stalled
W
=Waiting
on
someone
P
=Piloting
C
=Complete
Questions/Comments?