Lean Six Sigma in the AMEDD

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Lean Six Sigma in the AMEDD Part 1
William T. Humphrey, COL, MC
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Why LSS in healthcare?

• Healthcare too much hassle, too expensive
• Declining revenue and reimbursements
• Mandate to address the costs of inefficiency

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Why me?

• Duty to be a good steward of people, time, and
  other resources.
• Tired of getting beat-up over chronic access
  challenges
• Intellectually challenging and interesting
  closely related to clinical research
• Helps build strong arguments for big changes.

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A little about myself

• Commander, MEDDAC, Ft Huachuca
• Lean Six Sigma Black Belt
• Fellow, AAFP
• Diplomat, ACHE
• Certified Medical Staff Recruiter
• BA Music

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source of information

• Review of all 253 projects in the AMEDD
• My own research five projects to date

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Types of LSS projects

• Quick Win best for military medicine
• Rapid Improvement Event significant emotional
  event for MTFs as not really used to rapid change
• Full Scale DMAIC military leaders (at least in
  Army) lack the patience and strategic perspective
  required.

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attributes of current projectsregion
N 253
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classification of current projects
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classification of current projects
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classification of current projects
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classification of current clinical projects
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My current perspective on LSS

• hard work resource intensive intelligence and
  discipline required
• passion for excellence required
• right now the Army leadership is not really
  interested
• MTF acceptance slow (good enough for government
  work)
• Will not fix problems where real resource
  constraints exist

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Examples of LSS projects
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quick win

QUICK WIN
e.g. a clinic phone menu
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process map
quick win
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histogramfor distribution of data
quick win
USL
customer decides
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Correlation Scatter PlotCause and Effect
quick win
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Ishikawa diagramcause and effect
quick win
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Cause and Effect Matrix
quick win
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Value Add Analysis
quick win
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Interventions
quick win

• Apply Value Add Improvement Method
• Develop execute improved phone menu
• Measure Results

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New process map
quick win
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Capability histograms pre-post
quick win
time in menu (sec) - run 1 Count 128 Mean
78.633 Stdev 15.691 Range 128.0 Yield actual
3.15 Sigma actual -0.36
before
USL 60s
time in menu (sec) - run 2 Count 167 Mean
44.006 Stdev 6.4663 Range 56.0 Yield actual
98 Sigma actual 3.48
after
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Boxplots pre-post
quick win
USL 60s
N128
N166
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control chartpre-post
new menu
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quick win
SUMMARY
Increased calls getting through menu without
being dropped increased from 50 to gt99, a
2-fold improvement
Increased calls getting through menu lt 60s,
increased from 3 to 98, a 48-fold improvement
END OF QUICK WIN
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Rapid Improvement Event

Example 1 phone care
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DEFINE
define
optimizing phone care operations
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Project Charter
define

• PROBLEM STATEMENT phone care operations, manned
  by RNs, are designed as an overflow service when
  all appointments are booked. The problem is that
  the service does not have the capability of
  meeting many patient needs in a timely manner,
  which exacerbates and recycles unmet demand and
  causes frustration for patients and staff.
• OPPORTUNITY STATEMENT minimize the time required
  to execute phone care transactions, expand its
  scope to meets as many needs as possible given
  the telephonic format, and balance the capacity
  and demand of the service
• CLINICAL IMPACT The main clinical focus of this
  project is patient safety, ensuring they get
  their needs met in a timely manner. A second
  focus is creating more time for doctors to do
  disease management, preventive care, and episodic
  care.
• BUSINESS IMPACT The initial projection is in the
  range of 10,000,000 cost avoidance to the DHP
  (less issues referred out), cost avoidance to the
  MTF (less clinical time allocated the need), and
  cost recapture to the force and society (soldiers
  and family members spend less time in transport
  to and from clinic, waiting at the clinic, etc).
  Associated with our inefficient system.
• GOAL STATEMENT
• PRIMARY GOAL 5 minutes or less per in certain
  transactions involving medications, labs, and
  referrals
• SECONDARY GOAL create more capacity for face to
  face interactions
• TEAM MEMBERS RESOURCES
• PEOPLE Commander (BB), Chief Nurse, FCC,
  consultants from CAS, triage nursing, and LIP
• RESOURCES SigmaFlow, stopwatches, time-study
  forms, AHLTA
• PROJECT SCOPE
• IN-SCOPE simple medication/lab/referral
  transactions

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Change Management Overview
define

• WHY CHANGE? increased resource requirements to
  the AD force threaten our ability to care for
  FMs. Appointments are maxed out. Long queues
  form. Unmet demand is high.
• WHY NOW? Soon we will have to decide if we need
  to transfer more enrollees to the network. Before
  we do so, the throughput must be optimized.
• VISION STATEMENT Meet the patients need when
  the need arises without penalizing other
  patients. Create more face-to-face capacity from
  reductions in processing time
• HOW THE WORK WILL CHANGE
• Simple, straitforward transactions for
  medications, labs, and referrals will no longer
  be routed to in-house 20 min appt slots, nor to
  telephone consults. Instead they will be
  resolved by a provider-nurse team by telephone as
  soon as the need arises.
• WHO WILL BE IMPACTED AND HOW?
• doctors will focus on episodic care, preventive
  care, and disease management. They will be
  relieved from the burden of addressing
  transactions that do not require a standard 20min
  evaluation and management encounter.
• Patients requiring only simple transactions will
  receive immediate resolution of their issues and
  not be forced to compete for a limited pool of
  appointments. Patients requiring more extensive
  services will have a larger pool of appointments
  to compete for.
• The doctor-nurse team will be selected from a
  pool of current staff and receive special
  clinical training in the management of phone
  care.
• CAS agents will now screen all incoming calls
  against specific criteria. Patients who meet
  eligibility for fast track phone services will be
  routed to a doctor-nurse team.

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Raymond W. Bliss Army Health Center Project
Membership
define

• Project Owner commander
• Project Sponsor none
• Project Mentor none
• Team members Ms. Register (nursing), Ms.
  Hartwigsen (nursing), CPT Mukai (CAS), LTC
  Kreklau (LIP), MAJ Villafranca (management)

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RACI chart
define
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Voice of Customer (VOC) Conclusions
define
Source Patient Flow Efficiency BB project for
LJAHC
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Voice of BusinessBalanced Score Card and TSG
define
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Business Case
define

• Type 1 Real dollar savings none
• Type 2 Cost avoidance. Cost to employers
  associated with reductions in process time
  required for the care
• Type 3 No direct financial impact increased
  Customer (patients and providers) satisfaction
• Type 4 Revenue Generation. Associated with
  recapture
• dollars removed from budget and returned to
  higher authority or redeployed elsewhere
• savings applied to unanticipated costs/overruns
  within organization.
• No budget impact. Improved effectiveness or
  other strategic goal achievement. Increasing the
  dollars (over and above appropriated funds) that
  flow into a revolving fund.
• Revenue of appointments that fill the space
  previously associated with encounters for uneeded
  follow-up visits, rework, etc.

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SIPOC Map
define
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define
phone care high-level process map
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Communication Plan
define
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MEASURE
measure
optimizing phone care operations
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phone care LLPM
measure
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Data Measurement Plan
measure
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Baseline CapabilityPCT in minutes
measure
N 220 episodes USL 600min Mean 483
minutes defective 29.82 Sigma 2.03
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ANALYZE
analyze
optimizing phone care operations
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What gets handled over the phone
analyze
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Historical Daily Volume of Phone Care
analyze
N 123 days Mean 47 Stdev 12 Range 56
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Baseline Volume of Phone Careby day of week
analyze
Monday slightly busier than Thu (p0.002) and Fri
(p0.025) Variability within a day exceeds
variability between days, which supports a
constant staffing plan, except possibly after
training holidays.
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arrival patterninter-arrival time
analyze
Count 229 Mean 12 Median 8 Stdev 13 Range
77
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Preliminary studyWhat is the potential volume of
recapture in the DPC?
analyze

• Study design retrospective chart review of 750
  DPC face-to-face encounters
• Time frame 100 of face-to-face encounters from
  2-8 Aug 07
• Results 19 visits per day on average (range
  10-29) consisted of simple transactions (med,
  lab, referral) 14 of DPC business
• Conclusions Up to 1 FTE of appointment space
  could be created by redirecting simple
  transactions to the phone

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IMPROVE
improve
optimizing phone care operations
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rapid improvement event
improve

• Study design case-control study
• Control group (retrospective) traditional
  triage-phone consult system
• Study group (prospective) fast track phone
  consult system
• Time frame 5 consecutive days of patient care in
  July compared to 7 consecutive days of patient
  care in Aug
• Primary outcome variable transaction time
• Intervention Staff a phone clinic with a nurse
  and a doc from 0730 to 1000 daily.

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lean concepts employed
improve

• 5S sort, set in order, shine, standardize,
  sustain
• Remove clutter
• All needed resources readily available
• Phones with buttons routed to areas to offload
  work
• Stop watch to measure transaction time
• SOP and training
• All systems must be loaded at start time
• Establish generic pull work control system
• Exit triggers start (no interruption of current
  WIP)
• Current PCT 200min (median)
• Current PCE CVAT/PCT 2.5min/200min 0.0125
  1.25
• Target PCE 2.5min/10min CAS time new PCT
  25
• WIP cap 2tx/5min x 240min 96 per day
• Process Balancing Doctor and nurse cross train
  to assist each other as pooled resource

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fast track room layout
improve

• Set-up procedures
• Launch CAC-enabled computer that stays open
• Preload reference materials
• AHLTA documentation
• CHCS-1 order entry

bin stock Fast track SOP, sick slips, rx PADs,
etc. Reference materials
audiocare/microlog eqipped phone headset
bin
bin
computer
computer
phone list
time sheet
time sheet
phone list
RN
LIP
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new process
improve
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Simulationto determine ideal hours of staffing
improve
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Results of trial
improve
control group traditional phone consult (BEFORE)
N 220 USL 600min defective 29.82 Sigma
2.03
N409
study group fast track phone consult (AFTER)
N197 USL 600min defective 0.0 Sigma gt6
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Profit/Loss of 7 day trial
improve

• Revenue recapture (0.7 RVU/enc) earned(0.22
  RVU/enc) 32.3 RVU 2823.02
• Cost revenue lost (0.7 RVU/enc) 10.5 RVU
  917.70
• PROFIT 1905.32
• Cost avoidance to patients 1142.40
• TOTAL BCA 3047.72 (104,468 projected out over
  one year)

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Conclusions regarding fast track phone care
improve

• fast track phone care decreased average time
  required for the transaction (from the patients
  point of view from an average of 483 minutes to 4
  minutes)
• Provides for professional oversight of nursing
  triage care.
• Makes more appointment space available in the DPC
  for face-to-face encounters for those who really
  need it.
• fast track phone care Is cost effective.
• fast track phone care appeared to be as safe as
  the face-to-face encounter

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CONTROL
optimizing phone care operations
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Control Plan
control

• designate medical and nursing director of phone
  care to provide training and oversight
• Medical Director CPT (Dr) Lundell
• Nurse MAJ(P) Villafranca
• Fast Track Standard Operating Procedures posted
  at workstations (available on request)
• Staffing plan 0730 1000 with two work centers
  running in parallel. Modify as needed for busy
  days like Mondays or after training holidays
• Data monitoring
• Daily volume
• Quarterly transaction time study

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Rapid Improvement Event

Example 2 med refills
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DEFINE
define
optimizing refill pharmacy operations
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Project Charter
define

• PROBLEM STATEMENT Refill operations are
  conducted in the main pharmacy as well as a
  satellite pharmacy. The satellite pharmacy is
  rarely used, resulting in underutilization of
  staff and congestion in the main pharmacy with
  long waits.
• OPPORTUNITY STATEMENT Simplify refill
  operations, decrease congestion in the main
  pharmacy, optimize utilization of the refill
  pharmacy, ensure waiting time for refills meet
  customer expectations.
• BUSINESS IMPACT The main focus of this project
  is meeting customer expectations. The secondary
  focus is the dollars returned to force by
  reductions in waiting time.
• GOAL STATEMENT ensure no more than 20 minutes
  elapse in the total transaction process for
  refills.
• TEAM MEMBERS RESOURCES
• PEOPLE Commander (BB), DCHS (manager), Chief,
  Ancillary (manager) Chief Pharmacy (pharmacist)
  consultants from concierge desk, pharmacy tech as
  needed
• RESOURCES queue-matic software, SigmaFlow,
  Excel, Powerpoint, stopwatches, time-study forms.
• PROJECT SCOPE
• IN-SCOPE refill and main operations
• OUT-OF-SCOPE PIXUS operations, retail, TMOP
  operations

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Voice of the Customer historical satisfaction
with pharmacy operations
define
MEDCOM benchmark
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customer specifications for what good service
isN84
define
Survey of patients conducted July 07. Details
available by request
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customer specifications for wait timeN84
define
Survey of patients conducted July 07. Details
available by request
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Voice of Customer (VOC) Conclusions
define
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Voice Of BusinessBalanced Score Card and Joint
Commission
define
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Business Case
define

• Type 1 Real dollar savings none
• Type 2 Cost avoidance. Cost to force caused
  by waiting in queues
• Type 3 No direct financial impact increased
  Customer (patients and providers) satisfaction
• Type 4 Revenue Generation. none
• dollars removed from budget and returned to
  higher authority or redeployed elsewhere
• savings applied to unanticipated costs/overruns
  within organization.
• No budget impact. Improved effectiveness or
  other strategic goal achievement. Increasing the
  dollars (over and above appropriated funds) that
  flow into a revolving fund.
• Revenue of appointments that fill the space
  previously associated with encounters for uneeded
  follow-up visits, rework, etc.

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SIPOC Map
define
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Communication Plan
define
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MEASURE
measure
optimizing refill pharmacy operations
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Data Measurement Plan
measure
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process map for refills as is
define
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baseline refill capability of Satellite
pharmacytransaction times in seconds
Count 30 Mean 76.467 Stdev 41.214 Range
176.0 Minimum 25 25th Percentile (Q1)
41.250 50th Percentile (Median) 76 75th
Percentile (Q3) 106.75 Maximum 201
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ANALYZE
analyze
optimizing refill pharmacy operations
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simulation
analyze
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IMPROVE
improve
optimizing refill pharmacy operations
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Interventions in order of importance
improve

• Process streamlining decrease complexity at the
  main pharmacy 1 Oct 07
• Route all refills to the satellite pharmacy (i.e.
  stop doing refills at the main pharmacy)
• Transfer OTC program to the satellite pharmacy
• Stabilize staffing 1 Sep 07
• Plan for 80-90 of available window agents for
  staffing level

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FMEA before controls
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FMEA after controls
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improve
process map for refills future state Staff the
satellite refill pharmacy from 0700-1700 with
one tech and one for times of peak utilization
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Results of Changes
start
improve
volume predictable
satisfaction improving
start
Source APPLS
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Results of Changes
start
improve
Average QT only 1-2 minutes
Pre-thanksgiving surge, chief out of town
Max QT usually under USL of 20min
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results of trial
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CONTROL
control
refill pharmacy efficiency
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Control Plan
control
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Summary

• New refill pharmacy operations operating with 2
  staff from 0700 to 1700
• This pharmacy fills 100 400 scripts a day
• Average transaction time is only 1-2 min
• Max QT is under the USL of 20min 99.5 of the
  time for a Sigma of 3.94
• Patient satisfaction for overall pharmacy
  services is now at the highest level in 2 years

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SUMMARYevidence based improvements to date

• Family Practice
• Phone care is cost effective, efficient and safe
• It is possible for doctors to stay on time if
  they buy into good processes and share the work
• Walk-in services are expensive and inefficient
  due to variability in arrival pattern
• Well designed flow processes improve access and
  may improve safety (e.g. medication
  reconciliation)
• Processes that are patient centered (focus on
  care from the patients perspective) improve
  patient satisfaction
• Laboratory
• Lean Six Sigma initiatives reduce turn around
  times and reduce wastage of blood products
• Inpatient care
• SBAR is an effective handoff tool
• Medication reconciliation is a process

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SUMMARYProjects in progress

• Clinical
• Bed sore reduction
• Population health
• best practice for DM
• screening mammograms
• PAP smears
• Documentation
• Coping with AHLTA
• Speeding up the MEB process
• Productivity coding and RVU

Stay tuned!!