Advocate Performance Enhancement reaches Lutheran General Hospital

To read Volume I of Advocate's Adventure, please go here.

Advocate Performance Enhancement is a thoughtful and strategic approach to improving operational performance and patient care throughout Advocate. It provides a method of creating clear connections between Advocate's vision and individual work, and a plan of action for meaningful activities that are aligned with organizational goals.

Lutheran General Hospital is the second hospital in the eight-hospital system to begin on the Advocate Performance Enhancement journey. "Performance enhancement simplifies our processes one at a time," explains Julie Schaffner, Lutheran General's chief operating officer. Techniques like lean methodology have been used successfully in other industries to redesign work processes and dramatically improve quality. In addition to improving the work life quality at Lutheran General, our goal for patient safety is a zero-defect environment.

How is Performance Enhancement different from past process improvement initiatives?
"It is far more rigorous, far more focused and much faster," says Schaffner. Also, performance enhancement engages staff in the process redesign, gives them tools and provides time to focus on their redesign. It enables staff to "report out," or give regular project status updates, to senior management on a regularly scheduled basis, and it is aligned with our critical key result areas and strategies.

Table of Contents Timeline EVSA VSA MRI CPD Success Stories at Lutheran General

Timeline

Date	Rapid Improvement Event Activity
May 2007	Hospital EVSA (Leadership Strategy)
June 2007	MRI VSA (Planning Event)	CPD VSA (Planning Event)
July 2007		Decontamination Process
August 2007	Checklist Improvement
September 2007		Tray Assembly
October 2007	Room Turnover, Transportation, & Prioritization	IV Pump Distribution
November 2007	Sedation	Case Cart Assembly
December 2007	Approved to Test Completed Turnaround	Equipment Distribution
January 2008		Inventory Management

EVSA

In May 2007, the Lutheran General site steering committee held a 2.5 day enterprise value stream analysis .  Taking into account the priorities of the hospital, leadership within departments, and opportunities for success, magnetic resonance imaging and the central processing department were chosen as the initial focus to implement the lean methodology.

VSA

In June 2007, a three-day value stream analysis  was held for both MRI and CPD.  By incorporating lean tools, such as current state mapping, the VSA team was able to discuss initial concerns and identify the primary issues.  The teams also set goals for each department, including improved case cart completion and decreased outsourced MRIs.

MRI

Background

• Approximately 3,390 patients receive MRIs per year, resulting in about 550 scans per month (1 scanner)
• Scans can last anywhere from 20 minutes to 3 hours
• Patients need to be completely still for the duration of scan, otherwise the test will need to be repeated

Reason for Action

• Delays lead to increased wait times, resulting in decreased physician, patient and associate satisfaction
• Delays in diagnosis and treatment, increased costs and length of stay
• Delays lead to delays in admission, discharge, and diagnosis for ED patients

Goals/Target State
To provide timely notification of scheduled MRIs with minimal handoffs, appropriate prioritization and use of modalities resulting in satisfied customers (patient, physician and associates)

• Decrease the number of MRI outsourced at a cost/loss of $800 per scan
• Streamline the MRI prescreening process and assure patient safety by reducing the complexity of MRI checklists and processes
• Implement standard work procedures in all areas to increase productivity
• Synchronize flow and communication between MRI, nursing floors, and transportation and radiologists to increase throughput 
• Reduce inventory and supplies
• Decrease turnaround time

Results

• Reduced checklist turnaround time from 6 hours to 2 hours
• Reduced open time on the scanner from 54% to 24% and subsequently eliminated outsourced overflow 
• Reduction in linen supplies held in the MRI suite by $1000 
• Overall MRI order to patient receives test results has been reduced from 44 hours to 22 hours which is helping to produce same-day turnaround

CPD

Background
CPD provides a 24-hour supply of equipment, trays, linen packs, and disposables for units including, but not limited to, the operating room, ambulatory surgery, labor and delivery, and nursing units throughout the hospital.  On an average day, CPD:

• Transports and cleans 375 pieces of equipment
• Decontaminates 90 case carts
• Assembles and sterilizes 400 trays and 175 individual instruments
• Prepares 100 case carts with sterilized trays and disposable items

Reason for action

• Lack of effective communication between OR and CPD
• Unable to meet current demand of OR Cases
• Frequent searching for missing trays and rewashing of trays
• High variability in processing trays
• Phone calls interrupt workflow
• Lack of prioritization for processing case carts

Goal/Target State

• Implement standard work procedures in all areas
• Increase throughput of trays and instrument turnover through decontamination and tray assembly
• Complete 100 percent of case carts on the first pass
• Increase equipment availability 
• Proactive customer solutions and reduction in rework

Results

• 68 percent reduction in transportation of IV pumps throughout hospital
• 84 percent reduction in flow time between IV pump use and availability in high-use areas including the emergency department from 9 hours 25 minutes to 1 hour 30 minutes
• 47 percent improvement in completed case carts from 64 percent complete in 9/07 to 94 percent complete in 11/07
• Elimination of need for 250 additional IV pumps which resulted in $250,000 of captial savings

Success Stories at Lutheran General Hospital

Here are some examples of RIE success stories:

Value Stream: MRI
Rapid Improvement Event: Checklist Improvement
In August, inpatient radiology became the second department to identify and implement operational improvements in a specific work area using lean tools and techniques.  Under the leadership of executive sponsor Schaffner, a group made up of members from inpatient radiology, the Lutheran General and Advocate Performance Enhancement teams and patient care staff spent a week going through the rapid improvement part of the process. The goal was to streamline the MRI prescreening and assure patient safety by reducing the complexity of MRI checklists and processes.

During the first two days of the RIE, the team used techniques such as a gap analysis, flow mapping, time observations and spaghetti diagrams to find ways to improve the process. By Wednesday, they were ready to brief the nursing staff on the new approach and to "go live" with a revamped electronic-based checklist that streamlined and simplified the process. They then spent the final two days addressing any "bugs" that came up during implementation.

Value Stream: MRI
Rapid Improvement Event: Room Turnover, Transportation, and Prioritization
One of the hospital's most challenging projects was next: process streamlining and productivity improvement for the hospital's only inpatient MRI scanner.  The scope of the project was so large that it wound up being Lutheran General's first two-week RIE.

The team uncovered and tackled a number of roadblocks that negatively affected the time needed to complete MRI scans and transport inpatients to and from the MRI unit.  These included a mind-boggling 37 phone calls made throughout the MRI cycle, and an inefficient turnover time between patient appointments that resulted in long periods when the scanner wasn't in use.

Various performance enhancement tools were used to zero in on reducing MRI scan delays.  These helped to standardize the patient preparation protocol and hand-offs among nurses, MRI techs and transporters; increase scheduling reliability; adjust the MRI suite skill mix; and improve the work environment.  The ultimate result of these changes is shortened MRI scan turnovers and increased capacity, which boosts patient, physician and associate satisfaction.

Value Stream: CPD
Rapid Improvement Event: Tray Assembly
Assembly of instrument trays for surgical procedures performed at Lutheran General is a detail-oriented and time-consuming challenge. Depending on the procedure, trays can require as many as 700 surgical instruments or as few as one. Each instrument can be made up of several pieces Making sure these trays are efficiently and accurately assembled is critical.

Because of its impact on patient safety, tray assembly was the focus for the CPD's second RIE . The goal of the team that undertook this project was to improve associate satisfaction and relationships with the OR through improved workflow, efficiency, work stations and the quality of tray assembly.

"Ultimately, we're working toward having the right item at the right place at the right time in the right condition to improve clinical outcomes, patient satisfaction and financial performance," says Lloyd Hendricks, manager of central processing. To transform the work environment and routines in the area, the performance enhancement team utilized the '6S' --sort and scrap, straighten, scrub or sweep, standardize, sustain and safety.

The results of these efforts are improved work station ergonomics, standardized work processes for several CPD roles, reduced time searching for instruments or supplies, and less inventory overstock. A triage role was also added on all three shifts to prioritize tray assembly and divert interruptions from associates who are assembling instrument trays.

"I think the best feature of the performance enhancement initiative is the ability to bring together a group of individuals from different areas to participate in the RIE," adds Hendricks. "It brings different viewpoints and insights to the process."

Value Stream: CPD
Rapid Improvement Event: IV Pump Distribution
Central processing's RIE addressed the distribution and availability of IV pumps throughout the hospital.   Lutheran General's IV pump supply appeared to be inadequate, which caused delays in getting this essential equipment to patients.  Although the performance enhancement team initially considered acquiring more IV pumps, it helped resolve the problem through innovative process changes and standardized work for key positions.

Units that use many IV pumps, such as the ED, labor & delivery and the ICU, now have them cleaned on site by the CPD.  This dramatically reduced the equipment delivery/pick-up and cleaning turnaround time, making IV pumps more accessible. For other hospital areas, the CPD staff now picks up and delivers IV equipment at the same time, which has made the equipment more readily available for patients.  As an added benefit, the team discovered more pumps were not needed to meet hospital demands, saving an annual $250,000 rental fee for additional equipment.

Team member Roxanne Shimizu, emergency services, said she loved being a part of the RIE and summed up the performance enhancement experience by noting, "It's nice to work on a team that is looking for solutions, not excuses."

Our Insights and Lessons Learned
Two week, back-to-back rapid improvement event weeks in same department, while successful, will probably not occur again due to the demand on staff resources and labor intensity of the work

• Accelerated improvements are possible even when implemented technology house-wide
• Thorough preparation, including observation and data analysis before a RIE is very important and significantly impacts the success of the RIE week

Gemba Walks Give Leadership First-Hand Knowledge of Performance Enhancement Projects

In addition to attending the "report-out" session following the completion of each RIE, the leadership at LGH, as well as the system-level steering committee, took the opportunity in November to participate in a Gemba walk .  On this inaugural walk, the executives were able to observe firsthand the resulting improvements - and the processes followed to achieve those enhancements - for the areas of case cart assembly in the CPD, and inpatient/outpatient sedation in inpatient MRI.  

One of the main objectives of the Gemba walks is to provide an opportunity for leadership to understand what the process owners do and what their issues are. "These team members are the experts at their job function," says Robert Green, vice president of system operations, finance and performance enhancement."  Through this interaction of executives and team members, there is a natural building of relationships and break-down of barriers to change.  A connection can be made for all concerned between the specific efforts of each RIE team, and the global issues and strategy of the company."