3
rd
Lean Six Sigma Symposium
Working through the Continuum of Care in Rehabilitation
Long Island Chapter of American Society for Quality
Carolyn Sweetapple, RN, CPA, MBA Six Sigma Master Black Belt
¾Vital Statistics:
¾15 Hospitals
¾5.4 million population served
¾$4 billion in Revenue
¾33,000 employees
Nassau + + Suffolk Queens Kings Staten Island Manhattan # + + + ++ + + + + + + + + + + + + + + + + + + + + + + ++ + + + + + + + + + + + + + + + Key:Health System Hospital Competitor Hospital +
+
Case Presentation
Working through the continuum of care in rehabilitation
to improve throughput, decrease length of stay and increase revenue
using Six Sigma and Lean Methodologies
What is Rehabilitation?
Physical medicine and rehabilitation From Wikipedia
Physical medicine and rehabilitation (PM&R),
or physiatry,
is a branch of medicine which aims to
enhance and restore functional ability and quality of life to those with physical impairments or disabilities.
What is the Rehabilitation Continuum of Care?
Home Care
Hospital-based Therapy
Inpatient Rehabilitation Outpatient
Project Selection Criteria
Prominent service line for the organization with growth
opportunities – business case.
Each area of product depends upon efficient and effective
operations of the other in order to maximize outcome for
those patients who move thru continuum- value stream.
Data rich environment.
Commitment of hospital leadership to enhance/maintain
the financial and reputation of the rehab service .
Strong local leadership committed to improvement
process and sustaining the results.
Regulatory and reimbursement shifts in conjunction with
above heightened the need to insure efficient service,
accurate assessment and high customer service to
maximize market share.
FOCUS ON
HIGH PRIORITY AREAS WITH INEFFICIENCIES
Objective: Facilitate process evaluation, process redesign
and implementation to improve the flow of patients through
the rehabilitation continuum in a community hospital from
acute care through acute rehabilitation services and
outpatient care.
Challenge: How do you decide what methodology to use?
PLAN
CHECK
ACT
DO
Hospital Based Therapy - PDCA
)Regulatory requirements not met )Delays impacting length of stay
)Continuous improvement and monitoring needed
HOSPITAL BASED THERAPY – THE ISSUES
)Use PDCA when you need a dynamic model where completion
of one cycle flows into the beginning of the next resulting in continuous improvement
Problem: Time from physical therapy order to fulfillment exceeds specification of 48 hours. Results:
Process improvements resulted in turnaround time improvements to a mean
of 24 hours 99% of time.
Regulatory requirement of 48-72 days
Pareto Diagram 0 5 10 15 20 25 30 35 40 Is s u e 1 Is s u e 2 Is s u e 3 Is s u e 4 Is s u e 5 Is s u e 6 Is s u e 7 Is s u e 8 Is s u e 9 Is s u e 1 0 Is s u e 1 1 F requ en c y 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% C u m u la ti v e P e rc ent
Inpatient Rehab - Six Sigma
)Revenue impact significant
)Causes and solutions not apparent )Cross functional issue
)Previous improvement efforts only yielded partial success
INPATIENT REHAB – THE ISSUES
)Changes in culture needed for full efforts to be realized )Concerted cross functional effort needed
)Redesign of current system needed
)Strong financial business case to deploy the resources needed
DEFINE
DEFINE
Project:
Current processes are not allowing us to accurately assess
patients functional level and therefore the burden of care. This results in higher FIM scores
which reduces Medicare reimbursement.
Customer Demands:
Improve assessment accuracy Improve documentation accuracy
Increase revenue per patient Increase patient volume
Expedite admissions
Benchmarking against regional and national averages revealed that
our hospital was statistically significantly higher in scoring.
0 10 20 30 40 50 60 70 80 90 FIM SCORE
Admission FIM Scores
Southside Regional National
Southside 89.6 65.9 63.4 85.6
Regional 80.6 61.4 59.4 75.7
National 76.1 59.2 58.6 69.7
MEASURE
MEASURE
X X Walk/wheelchair 12 X X X Toilet 10 X X X Bed. Chair 9 X Bowel 8 X Bladder 7 X Toileting 6 X X X Dressing-Lower 5 X X Dressing-Upper 4 X X X Bathing 3 X Grooming 2 Regional variance Other system hospital variance Internal variance Description FIM Item #Problem Measurement
and Data Gathering:
Defect was defined as
Assessment scores not measured all three days of
patient admission using standardized algorithm.
Medical record reviews were performed and therapists were shadowed
to quantify defects.
Results:
65% of the time we do not meet our customer’s specifications
Goal:
20 40 60 80 100 120 140 160 Number of pts. AssessedANALYZE
ANALYZE
0 20 40 60 80 100 120 140 160Day One Day Two Day Three
Number of pts. Assessed
Identifying independent variables that determine CTQ behavior:
Process Analysis & Data Analysis
X4= No standardized process followed to perform assessment
X3= Assessments not performed on all 3 days X2= Assessment not performed until day 2 X1= Delay in admission after acceptance
Critical X’s
1 2 3 Total 1 0 149 48 197 65.67 65.67 65.67 2 197 48 149 394 131.33 131.33 131.33 Total 197 197 197 591 Chi-Sq = 65.667 +105.753 + 4.753 + 32.833 + 52.876 + 2.376 = 264.259 0 1 0 2 0 3 0 4 0 5 0 6 0 7 0 6 9 5 8 7 2 1 0 3IMPROVE
IMPROVE
497 79 429 147 381 195 0 50 100 150 200 250 300 350 400 450 500 # Lowest score # Non-lowest scoreResults:
The defect rate was reduced to 10% resulting in $500,000 additional revenue for the hospital annually
Improvements Implemented:
Patients admitted day of
acceptance rather than 2 or more days later
Admission times before noon,
rather than late afternoon
Standardization of process Reassessment process, which
includes assessment of patient on day 1 of admission, as well as day 2 and day 3
Chi-Square Test: DAY 1, DAY 2, DAY 3 Expected counts are printed below observed counts
DAY 1 DAY 2 DAY 3 Total 1 79 147 195 421 140.33 140.33 140.33 2 497 429 381 1307 435.67 435.67 435.67 Total 576 576 576 1728 Chi-Sq = 26.806 + 0.317 + 21.295 + 8.635 + 0.102 + 6.859 = 64.014 DF = 2, P-Value = 0.000
CONTROL
CONTROL
Ensuring Sustainable Results: Changes imbedded in departmental processes Owners continue to monitor with control chartsand intervene if trends are observed
Results:
Results were sustained and revenue gains continue to
be realized Tools Used:
Control Plan SPC
Risk Assessment Plan Communication Plan 0 10 20 30 40 50 60 0 50 100 Sample Number De fe ct Ra te U=64.6 UCL=92.38 LCL=43.02 Goal = 20 Actual = 9
Outpatient - Lean
)Delays in access time.
)These delays caused further inefficiencies and lost business –
no shows and cancellations.
)Capacity constraints limited growth in volume although
demand existed.
OUTPATIENT PHYSICAL THERAPY – THE ISSUES
)Improve what exists (process improvement)
by removing waste and non-value added steps.
)If you see queues or disorder, think LEAN.
)Lean improvements create flow and throughput.
Insurance Verification & Registration Insurance Verification & Registration Clinical Intervention Clinical Intervention Intake Intake Charge Input Charge
Input DischargedPatient Patient Discharged
Scheduling
Scheduling
Ambulatory Rehabilitation Access to Care Project Description:
To create an integrated outpatient service that responds to the needs
of our patients and physicians, is effective and efficient and can adjust
to changes in the therapeutic environment.
Ambulatory Rehabilitation Access to Care Project Description:
To create an integrated outpatient service that responds to the needs
of our patients and physicians, is effective and efficient and can adjust
to changes in the therapeutic environment.
Mean of 169 hours
Standard deviation of 88
>79% of cases exceeded
the target of 96 hours
4 0 0 3 0 0 2 0 0 1 0 0 0 U S L P ro ce s s D a ta S a m p le N 2 5 S tD e v (W ith in ) 7 4 . 4 5 5 2 S tD e v (O v e ra ll) 8 8 . 4 0 2 2 LS L * T a rg e t * U S L 9 6 S a m p le M e a n 1 6 9 . 6 4 8
P o te n tia l (W ith in ) C a p a b ility
C C p k -0 . 3 3 O v e ra ll C a p a b ility P p * P P L * P P U -0 . 2 8 P p k C p -0 . 2 8 C p m * * C P L * C P U -0 . 3 3 C p k -0 . 3 3 O b s e rv e d P e rfo rm a n ce % < LS L * % > U S L 8 4 . 0 0 E xp . W ith in P e rfo rm a n c e % < LS L * % > U S L 8 3 . 8 7 E xp . O v e ra ll P e rfo rm a n c e % < LS L * % > U S L 7 9 . 7 6 W ith in O v er a ll A c c e s s to C a r e ( C O R ) P r e -i m p r o v e m e n t
BEFORE LEAN
AFTER LEAN BEFORE LEAN:
Access to outpatient services
averaged 169 hours exceeding customer specification of 96 hours
Customers dissatisfied and
business lost
>79% of cases exceeded the target
of 96 hours
AFTER LEAN:
Access to outpatient services
averaged 100 hours
Eliminated 11 steps
Saved $45,000 per year in labor
costs
Improved access to care by 3 days
Patient contacts department (telephone)
Obtain Dx /
problem ID insurance carrier
PAR Non-par Self pay pricing Refer out Product line triage No Yes Demographics Patient put on hold Information entered into Spectrasoft Back to phone Schedule appointment Give patient instructions / directions Phone conversation completed Intake form copied Intake book Pre-registration Walk in Insurance cards, ID and script copied Walk in Patient contacts department (telephone) Obtain Dx / problem ID insurance carrier PAR Non-par Self pay pricing Refer out Product line triage No Yes COR Demographics Intake form filled out Patient put on hold Information entered into Spectrasoft Back to phone Schedule appointment Give patient instructions / directions Phone conversation completed Intake form copied Copy to Margaret Stat Sheet Stat sheet toDonna Entered into spreadsheet Intake book PFS Call insurance Verification, authorization, precert Courtesy call to patient Pre-registration Registration Walk in Insurance cards, ID and script copied Walk in Information forwarded to manager Manager reviews and determines schedule Call ends Call back patient SSHI Waiting Overproduction
)Regulatory requirements met )Length of stay decreased
)Turnaround time improved to a mean of 24 hours
)Additional revenue of $ 500,000 annually realized )Admission to acute rehabilitation services from
the hospital improved from 10% to 50% after intervention on day one
)Access time improved from 6 days to 3 days
)No show/cancellation rate improved from 18% to 12% )Staff productivity allowed for increased capacity
HOSPITAL BASED THERAPY - PDCA
INPATIENT REHAB - SIX SIGMA
OUTPATIENT PHYSICAL THERAPY - LEAN IMPROVEMENTS
C O N C L U S I O N S
The use of Clinical Audit tools with Six Sigma and Lean
methodologies were effective to improve performance in
rehabilitation services in a community hospital.
This explicit and detailed use of the complementary
methodologies to efficiently and effectively move patients
through the continuum of care is easily replicable to other
Characteristics of Effective & Sustainable Projects
Project scoping
Leadership commitment
Strength of process owner
Identification of barriers (people and resources) early
with a plan to address
Sensitivity of political environment
Correct identification of vital independent variables
Strength of improvements
Change management efforts
Ease of measurements
The Krasnoff Team
Led by
Yosef D. Dlugacz, Ph.D.
Diverse team composed of:
Six Sigma Master Black Belt & Green Belts
Chief Nurse Executives
Certified Public Accountant
Quality Management Executives
Case Management Specialists
Registered Nurses Communication Specialist Physician Research Analysts Data Analysts Program Manager