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Delivering Healthcare in Efficient Environment

Joy ChakrabortyDirector - Administration

Hinduja Hospital, Mumbai.

The Challenges & Transition in Healthcare

Controlling costs Government regulations Government regulations Increasing competition Implement new procedures and capabilities Treatment reimbursement rates are capped

based on diagnosis Number of uninsured

Contd..

New technologies are Expensive and adoption in questionStaff shortages in some areas continue to drive up Staff shortages in some areas continue to drive up costsReport Cards on providers quality, cost, number of procedures Role of the Private Sector in healthcare delivery Growth in the number of people age 65 and

older

Favorable patient outcomes

Patient safety

Implement new procedures and capabilities

What do our Patients want ?

Implement new procedures and capabilities

Controlling healthcare costs

Service with a smile

What does the hospital want?What that leads to:

Available and prompt care

Better patient outcomes

Increased patient satisfaction

Improved financial viability Smooth operations

Ensure patient safety

Provide quality care

Effective patient treatment

Utilized staff and resources

Improved financial viability

Improved patient throughput

Improved publicly reported information

Higher employee involvement and satisfaction

Reduced LOS

How do we achieve this? By Improving By Improving QUALITYQUALITY of health careof health care

Patient safety and risk management

Evidence-based practice

Continuous learning and improvement

Stimulate and improve integration and Stimulate and improve integration and Stimulate and improve integration and Stimulate and improve integration and management of health servicesmanagement of health services

Reduce variation in care and health care costsReduce variation in care and health care costs

Strengthen the publicStrengthen the publics confidence in the quality of s confidence in the quality of health carehealth care

How do we achieve this ?

MUDAMUDA

Waste

Examples of Waste

Inventory unneeded stock or suppliesMotion movement of staff and informationOverproduction - unnecessary testsExtra processing filling out extra paper workExtra processing filling out extra paper workTransportation movement of patients & equipment Defects duplicate work, medical errorsWaiting delays in diagnosis & treatment

What is Lean?

Lean means creating more value for customers with fewer resources & elimination of wastecustomers with fewer resources & elimination of waste

Vs

Six Sigma is:

A disciplined, data-driven approach and methodology for eliminating defects in any process

A statistical representation of Six Sigma describes A statistical representation of Six Sigma describes quantitatively how a process is performing

At many organizations Six Sigma simply means a measure of quality that strives for near perfection

6 Level Performance

Six Sigma standard of 3.4 problems per million opportunitiesopportunities

3 Sigma standard of 67000 problems per million opportunities

4 Sigma standard of 6200 problems per million opportunities

Nature of Healthcare Business

- Outcomes are Variable in Nature

Six Sigma in Health Care In a HOSPITAL, processes must run correctly

The best option for healthcare organizations is to implement Six Sigma because It focuses on total improvement with reducing costs,

Improving performance and productivity, and Improving performance and productivity, and

Ensuring the patient is entirely satisfied with the care he receives

It allows professionals to appropriately and successfully figure the inconsistencies within their operations

It allows medical professionals the ability to detail processes within the field and quickly adjust and standardize them

Lean

6

Lean Six Sigma

Total Quality Management

Quality Assurance

Quality Control

Inspection

Lean + Six SigmaLEAN SIX SIGMA is a business improvement methodology which combines tools from both Lean and Six Sigma.

Lean and Six Sigma are complementary in nature

Lean focuses on eliminating non-value added steps and activities in a process, Six Sigma focuses on reducing variation.

DMAIC: Basics

MeasureDefine ImproveAnalyze Control

What is important to the customer:

The process:

Analyze Data

The process gains:

Ensure Solution is to the customer:

Project Selection

Team Formation

Establish Goal

How well we are doing:

Collect Data

Construct Process Flow

Validate Measurement System

Analyze Data

Identify Root Causes

Ensure Solution is Sustained

The process performance measures:

Prioritize root causes

Innovate pilot solutions

Validate the improvement

Disruptive Innovation

Benefits of Lean Six Sigma

Improved patient experience and satisfaction Faster response to patient needs Increased job satisfaction & reduced stress for

caregiverscaregivers Improved, standardized & repeatable processes that are

more predictable Ability to focus resources on more value-added activities Improved asset utilization: people, equipment &

technology Reduced unit costs through increased capability

Benefits of Lean Six Sigma

Improved flow through elimination of bottlenecks (delays) and constraints (limiters)

Dramatic improvement in scheduling predictability Dramatic improvement in scheduling predictability better process management

Participative problem-solving

Engaging the people who know and do the work the team

Recognition of the need to manage change

Tools

Hypothesis testingFish Bone Analysis

RegressionVOC

Cause & Effect Matrix

Its not about tools to achieve Its not about tools to achieve success in Lean Six Sigma. Its about how to get leaders to believe in and

EMBRACE quality!

Real Life ApplicationOrganization Project Outcome Achievement

Charleston Area Medical Center

Supply chain for surgical supplies

Lower inventory, Improved supplier relations

Saved:$163,410 immediately $841,540 future

CommonwealthHealth Corporation

Radiology Decreased time between dictation and signature, Improved wait times and staff scheduling

$800,000 savings, 25% better throughput and eliminated 14 positions

Froedtert Memorial ICU lab times Reduced turnaround Cut turnaround times from Lutheran Hospital times 52 to 23 minutes

Mount Carmel Hospital

Medicare+ Choice Plan reimbursement

Redefined coding working-aged Medicare recipients

Profit $857,000

Wellmark Inc. Physician addition to managed care network

Reduced time for adding physicians to medical plan

Savings: $3 million per year

Scottsdale Healthcare

Over crowded ED

Improved transfer time from ED to inpatient hospital bed

Profits: $600,000

381 beds, including 53 ICU beds; 19 Short Stay Service;

11 Operation Theatres and 6 EICU beds

Not for Profit Hospital

140 Consultants; 510 nurses and other support staff

Exclusive area for Preventive Health Checks

An Overview

Exclusive area for Preventive Health Checks

Promoting Medical Education along with attached Nursing College

State of the Art Technology Application

Group is entering into For Profit Segment in Healthcare

Well stocked library with over 417 latest online and

offline journals. 26

PioneeringBest Practices movement @ HNH

College of American Pathologists (CAP) (1st hospital laboratory to be accredited among the SAARC region countries);

ISO certification in 1996

Recipient of Ramakrishna Bajaj award for healthcare quality.

Participation in Best prax Club competition

ISO 27001 for IT Department for Information Security

Hospital accreditation

Hinduja hospital six sigma Hinduja hospital six sigma

success story

FIRST HOSPITAL to adopt six sigma in Healthcare in India

Recently, concept of Lean Six Sigma has been applied too.

Some Studies :

Turnaround time for patient discharges Outpatient Satisfaction Outpatient Satisfaction Turnaround time for Imaging reports Satisfaction for Peri - operative care Average Length of Stay Operation Theatre support services OPD waiting time Discharge waiting time X Ray turnaround time Pharmacy items turnaround time

Case Study # 1

Short Stay Services.

1. 300 identified surgeries across 8 surgical specialties 1. 300 identified surgeries across 8 surgical specialties in scope.

2. 19 bedded dedicated self dependent unit with two units

3. Preoperative investigations and post-operative follow-up done at home.

4. 24 hrs in house dedicated call centre managed by nursing personnel.

Care @ Home Services

1. Expansion of reach.

2. Range of services provided

Measurable Outcome

Year Installed Bed

Capacity

No. of Surgeries

done

Avg Lengthof Stay

Capacity done

09 -10 383 11089 4.9 Days

10 - 11 372 12149 4.7 Days

Lean Six Sigma Process Improvement Project at Hinduja Hospital

Project Name : Reducing the Turn Around Time for Outpatient (OPD) Services

Case Sudy # 2

Project Goal : To reduce the Idle Waiting time in the Outpatient process by 30-50%

Define PhaseProblem Statement: Over the past few months it has been observed that the Turn Around Time for patients to avail OPD services has been an issue of concern for the patients and Hinduja Hospital.

Voice of CustomerVoice of Customer

Selection of the project on Reducing the waiting time in Out Patient Services is based on the concern raised by patients on waiting time in the regular OPD feed back forms & verbal communication to our customer care.

Voice of the customer was used to determine the acceptable Idle Waiting Time.

Measure Phase

Data collection : The entire process flow for consultation / investigation was tracked throughout the OPD working hours using tracking sheets.

The activity was divided into sub processes & the overall findings were :

Queue Time : 5-7 min Queue Time : 5-7 min

Vouchering Time : 3-4 min

Travel Time : 5-7 min

Idle Waiting Time : 40-50 min

All TAT other than the Idle waiting time are within their respective acceptable limits and hence not taken up for further study

Acceptable limit for the Idle Waiting Time is considered to be 30 minutes.

Waiting time for the OPD Services (in mins)

ServiceQueue Time

Vouchering Time

Travel Time

IdleWaiting

Time

Total Waiting

Time

Pulmonology 5 4 5 19 33

Cardiology 3 3 4 10 20

Neurology 4 4 10 45 63

Measure Phase

Neurology 4 4 10 45 63

Laboratory 6 3 2 10 21

X Ray 8 1 3 17 29

Physiotherapy Retrospective billing 8 8

Urodynamics Retrospective billing 29 29

Scopy (UGI, LGI) Retrospective billing 47 47

Bronchoscopy Retrospective billing 28 28

Consultation 4 4 3 33 44

Analyze Phase

A further investigation was done of the services which have Idle Waiting Time beyond 30 minutes

Neurology

UGI / LGI Scopy

Consultation

Neurology services Idle Waiting Time

EMG 101

EEG/ BERA/ VEP/ SSEP 21

EMG

Analyze Phase

Idle Waiting Time EMG is done in 2 steps : 1.NCV 2.Complete EMG

First step is conducted by the Neurology Technician & the second step is done by the Consultant. The increased Idle waiting time was observed in specific cases of pediatric neurology wherein the patients were uncooperative & had to wait for patient to settle down.

Wrong Date

Wrong Dr.'s Name

WRONG APPOINTMENT

Wrong HH no.

Wrong Time

Wrong details captured at time of giving Appointment

BILLING

Wrong HH no. entered at time of vouchering

Conversion of EX patient to HH patient

MRD FILE NOT RECEIVED

File not requested

File archived

DR NOT AVAILABLE

Dr. on Rounds / Procedure

Dr. in OTDr. gone for Emergency

Dr. Delayed for miscellaneous reasons

Appts after 8pm not reflected in appt list since list printed before 8pm

Analyze Phase : Consultation

Requested file not reflecting in MRD Delta report

WRONG APPOINTMENT

Dr.'s Instructions

Slot not available

Wrong Appointment

DOUBLE APPOINTMENT

BILLING

PATIENT LOST

Patient cannot find location

Wrong Instructions given

Training of new staff

NURSE NOT AVAILABLE

Nurse busy with Dr. or Patient

Tea Break

Shortage of Nursing Staff

MRD FILE NOT RECEIVED DR NOT AVAILABLE

PATIENT DELAYED

Emergency Patient

Previous patient taken in late

Patient came lateDr.'s

Instructions allowing Non Appointment Patients Walk-ins

Improve Phase : Solution Matrix Consultation Idle Waiting Time

Process Step Constraint Cause Solution

Appointment Checking Slot Patient called as Slot not available

Non appointment patients to be seen after the appointment patients as per Dr. instructions

Non appointment patients taken in advance only if the next Appointment

SchedulingChecking Slot Availability

Patient called as non appointment patients

advance only if the next patient has not arrived

Reserve specific slots in between appointment slots for non appointment patients

Slot is available but cannot take appointments on same day due to system limitations for file retrieval

System change to reflect the file request for same day appointments

Process Step Constraint Cause Solution

Printing of Appointments could not be taken on

File request not reflected in the MRD report for the same

System change to reflect the file request for same day

Improve Phase : Solution Matrix Consultation Idle Waiting Time

File retrieval in MRD

Printing of Delta report

not be taken on same day

report for the same day

for same day appointments

Printing of Appointment list

Updated appointment list not available

Appts after 8pm not reflected in appt list since list printed before 8pm

Any additional appointments after the list is printed are added by the Nurse in the appointment list and informed to the Doctor

Wrong Date

Wrong Dr.'s Name

WRONG APPOINTMENT

Wrong HH no.

Wrong Time

Wrong instructions given

PATIENT NOT PREPARED

Training of Call Centre Staff

PROCEDURE DELAYED

Dr. Delayed

Emergency patient taken

Dr. on Rounds

Dr. in ProcedureDr. gone for

Emergency

Dr. Delayed for miscellaneous reasons

Patient Delayed

Endoscopy Suite not available

Patient misunderstood instructions

Patient did not follow given instructions

Aerated Lime drink not available

Patient arrived late for preparation

Analyze Phase :UGI/LGI Scopy

WRONG APPOINTMENT

Outpatient Wilkins

Inpatient sent randomly

DOUBLE APPOINTMENT

PREPARED

DR.'S PRESCRIPTION NOT AVAILABLE

Patient forgot Dr;'s prescription

Dr. not available to give fresh prescription

SCOPY SUITE NOT AVAILABLE

Cleaning

PROCEDURE DELAYED

Non Appointment Patients- Wilkins

DR NOT AVAILABLE

PATIENT DELAYED

Emergency Patient

Previous patient taken in late

Patient came late

Inpatients sent randomly

Previous patients procedure ongoing

No Appts given to inpatients

Previous patients procedure ongoing

U. P. patient taken previously

Consecutive slots for Multiple procedures not available

Overlapping Appointments

Improve Phase : Solution Matrix Scopy Idle waiting Time

Process Step Constraint Cause Solution

Appointments taken for Inpatients

Reserve slots specifically for Inpatients / Inpatients only

Appt for Procedure

In patient Appt

Inpatients being taken randomly in between scheduled patients

No appointments taken for Inpatients

Inpatients / Inpatients only taken in vacant slots

Inpatient taken after all Out patient Appts

Assign point of contact in Scopy who will co-ordinate with Floor Nurses to ensure the Inpatients are taken in a scheduled manner

Process Step Constraint Cause Solution

UGI is a shorter procedure than LGI but the same single slot (of 30 min) is given

Only single slot allotment done in system: Overlapping

Changes in slot scheduling : 1 Slot 30 minutes for shorter procedures and 2 slots of 30 minutes each for longer procedures e.g. Colonoscopy

Improve Phase : Solution Matrix Scopy Idle Waiting Time

Appt for Procedure

Appt Scheduling

(of 30 min) is given when scheduling all the appointments

Overlapping appointments

procedures e.g. Colonoscopy will be given 2 slots instead of 1 slot

Separate slot timings given for multiple procedures on same patient when If continuous slots not available but procedure done consecutively

Slot not available consecutively for multiple procedures

Multiple process should be given consecutive slots and if required rescheduling of next patient

Process Step Constraint Cause Solution

If Scopy

Delay for next patient when patient is ready

Patient came late for preparation / Patient did not follow Dr.

When preparation to be done in Hospital, Appointment Cell to ask patient to follow Dr.'s instruction at time of giving appointment and call a day prior to confirm

Improve Phase : Solution Matrix Scopy Idle Waiting Time

If Scopy patient is not prepared

Patient given preparation at Hinduja Hospital

when patient is ready for procedure

did not follow Dr. instruction

and call a day prior to confirm the same i.e. patient to come to Hospital at least 2 hrs earlier /as per requirement

Requisite preparation solution not available

Patient did not bring along the requisite aerated drink required for preparation

Cafeteria to deliver the aerated drink for the patient

Performance: Consultation and Scopy

Idle Waiting Time

(in min)

Mean SD Sigma Level

BEFORE TARGET AFTER BEFORE TARGET AFTER BEFORE TARGET AFTER

Consultation 33 15 14 36 5 11 -0.06 3 1.45

Scopy 47 30 25 35 5 21 -0.07 3 1.70

Waiting time for the OPD Services (in mins) - YR 2010 vs YR 2011

Service

PRE LSSIdle

Waiting Time2010

POST LSSIdle

Waiting Time2010

FOLLOW UP Idle

Waiting Time2011

Pulmonology 19 19

Cardiology 10 10

Neurology 45 25

Laboratory 10 05

X Ray 17 09

Physiotherapy 08 01

Urodynamics 29 46

Scopy (UGI, LGI) 47 25 30

Bronchoscopy 28 35

Consultation 33 14 18

Case Study # 3

Project Name : Reducing the Turn Around Time for Patient Discharge

Project Goal : To reduce the Patient Discharge Time by 30-50%

Average TAT for Patient Discharge beyond 2 hours is considered as a defect.

Average Times (in minutes)

BEFORE AFTER

y1= Written order to Finance folder sent

85 18

y2 = Finance Folder sent to received in Billing9 7

y3= Finance folder received to taken for billing8 88 8

y4= Finance folder taken for Billing to Discharge Slip given to relative

50 48y5= Discharge Slip given to relative to receipt by nurse

21 19

y6= Discharge Slip received by nurse to patient physically leaves bed 22 21

Y = Written Intimation to Patient leaves floor 194 121

Performance: Discharge Process

Mean Max SD

BEFORE TARGET AFTER BEFORE TARGET AFTER BEFORE TARGET AFTER

y1 (in min)

85 40 18 385 50 45 94 5 9

y4(in min)

50 30 48 188 50 89 36 5 16

Y (in min)

195 120 121 525 150 205 108 5 22

DID YOU KNOW.....??

..Do you Know ?

Hospitals report that the biggest challenges in implementing lean or six sigma include sustaining improvements, competition from other initiatives, leadership commitment and availability of resources

- American Society for Quality, 2009

The Week The Week IMRB Exclusive IMRB Exclusive survey ranks Hinduja Hospital as survey ranks Hinduja Hospital as survey ranks Hinduja Hospital as survey ranks Hinduja Hospital as

no. 1 in the region for the 4th no. 1 in the region for the 4th year consecutivelyyear consecutively

54

Thank You