Process Improvement Anyone Can Do: Basic Tools and Concepts

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Process Improvement Anyone Can Do Basic Tools
and Concepts

• Karl B. Palmer, RN
• Rural Quality Program Conference
• Washington, D.C.
• September 2, 2009

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Red Cedar Medical CenterMayo Health System

• Located in Menomonie, Wisconsin
• Approximately 40 providers, all employed by the
  Medical Center
• Provider-Based Clinic (department of a 25 bed
  Critical Access Hospital)

• 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
• Family Practice, Internal Medicine, Pediatrics,
  OB/GYN, Podiatry, Occupational Medicine,
  Orthopedics, General Surgery, Sleep Medicine,
  Behavioral Health, and Physical Rehabilitation

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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

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Just a Bit About Me

• 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 yousome classes and coursework, but the
majority of my process improvement education Has
been learn by watching and doing.
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Tools We Have Used, That You Can Too!

• Flow chart
• 5-whys
• Inter-relations diagram
• Impact wheel
• Associative problem solving
• PDSA
• Matrix

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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)

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Reality CheckCulture eats process for breakfast!
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Flow Charting

• Why To better understand the current state of
  affairs (or possibly plan future processes)
• Keep it simple- just visually represent a process
• 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)
• 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).

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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

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Simple Visual Flow
Based on the Adaptive Design concepts of Dr.
John Kenagy
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Basic Formal Flowchart Symbols
Start or End
Activity
Decision or Question
Off Page Connector
Activity
Document
Delay
Start or End
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An Actual Example
Illness, Injury or need for care
(vvariation 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 Re-Triaged by Provider (V)
Medical Care or Patient Re-Triaged by Provider (V)
Medical Care or Patient Re-Triaged by Provider (V)
Patient leaves
Patient leaves
Patient leaves
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The Message

• Dont Be Afraid of Flowcharting!
• JUST DO IT!

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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!

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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.
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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? -Done -see 2b -see
2c -Too many off
-Long term absence Why?
Why? -No enforced rules
-see 2a
Why? (2a, 2b, and 2c are additional 5 why
branches) -Rules old -0 buy
in Why?
Why? -Not reviewed -Whats in it for
me? Why? Why? -No one
responsible -Value on family time -Done
Effective solution from this 5 Why-Form
a responsible provider Access Committee to create
and maintain staffing guidelines
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Now, we try it with your Problems!
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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.

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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.

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Interrelations Diagram for Preoperative History
and Physical Problems
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.
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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)

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FINANCIAL
MEDICATIONS
LAB
VISITS
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3 Out, 0 In
Primary Driver
FINANCIAL
MEDICATIONS
LAB
1 Out, 2 In
0 Out, 3 In
VISITS
2 Out, 1 In
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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.

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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

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Impact Wheel
Patient outcomes improve
Statistics (process measures ) improve
Budget Cuts -
Docs have info to make clinical decisions
Layoffs -
Revenue Decreases -
More patients will Come in for testing
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 -
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Lets Try One

• What if your hospital/clinic only offered
  vegetarian food choices in the employee cafeteria?

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Staff feel tired -
Cafeteria unable to sustain vegetarian-only menu
Cafeteria revenue drops -
Less staff Will eat at work-
Profit margin for cafeteria Will decrease -
If we only offer vegetarian food for staff, then
Morale will improve
Employee obesity levels will go down
Employees will feel healthier
Lower premium prices over time
Less health insurance claims
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Associative Problem Solving

• Very unique method of getting teams to think
  outside of the box
• Can unlock the creativity of employees

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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.

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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?

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Patients not coming in for recommended diabetes
visits What would Oprah do?

• Send a limo
• Build a clinic closer to the patients house
• Send a doctor to the patients house
• Do Oprahs book club on a diabetes book so that
  millions of women read it and realize the
  importance of visits
• Far fetched?

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Patients not coming in for recommended diabetes
visits What would Oprah do?

• Send a limo (offer taxi vouchers)
• Build a clinic closer to the patients house
• Send a doctor to the patients house (outreach
  activities, partner with public health or nursing
  schools)
• Do Oprahs 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)

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Patients not coming in for recommended diabetes
visits What would a 5 year old do?

• Call his friends mom to see why he wasnt coming
  over
• Get some new toys so his friend would come play
• Throw a party
• Be extra nice
• Have hold his friends hand on the way over

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Patients not coming in for recommended diabetes
visits What would a 5 year old do?

• Call his friends mom to see why he wasnt 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
  give-away)
• Be extra nice
• Have hold his friends hand on the way over
  (facilitate the formation of community buddies)

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Patients not coming in for recommended diabetes
visits What would a pro football player do?

• 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.

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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)

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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

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http//www.ihi.org/IHI/Topics/Improvement/Improvem
entMethods/Tools/Plan-Do-Study-Act28PDSA29Work
sheet.htm
Available if you have an IHI login and is Free
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Matrices

• Keep you organized
• Visual, dashboard type way to communicate status
  of interventions

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Questions/Comments?