Building a Plan for
Process Improvement
(Rapid Fire PI Workshop)
Lynn Hundley MSN,APRN,CNRN,CCNS,ANVP
Melissa Richardson MSN,RN,SCRN
Questions
•
Does your organization have legacy problems
Disclosures
Lynn Hundley:
Speaker bureau for Medtronic
Melissa Richardson:
No disclosures
Objective
The attendee will be able to…
Special thanks to Bill
Harrington who has taught me
many lessons about living
through PI!!
Philosophy of PI
•
Understand what are the most important problems
•
Don’t try to solve too many problems at once
Examples of Scientific Methodology
PDCA
DMAIC
Phase Objectives
1
P
lan
D
efine
Find a process to improve
Organize team that knows the process
Define the problem(s) to be addressed
2
P
lan
M
easure
Understand the current state of the process and problem (OBSERVE)
ID / Develop key metrics and get data
ID key barriers to investigate further
3
P
lan
A
nalyze
Determine what in the process adds value and what does not
Understand causes for key barriers
4
D
o,
C
heck
I
mprove
Determine the direction of how the problem will be solved
Detail the solution
Seek approval, train, and implement the change
5
C
heck,
A
ct
C
ontrol
Validate the problem has been solved and process is improved
Create and execute plan for sustaining improvement (study and grow)
Document lessons learned (cultural & technical), seek replication
Tools
Business Case
Problem Statement
Key Players
Customer(s):
Sponsor:
Team Members:
•
•
•
Success Measures and Goal
In Scope
Out of Scope
Milestones
Communication Plan
Patient arrives via Ambulance with stroke
symptoms
Patient arrives via Private Transport with
stroke symptoms
Obtain and document last known well
Last known well < 8 hrs
Triage based on condition No
Begin initial stroke response
Acute Stroke Checklist ED MD visit in <10 min Confirm last known well Check blood glucose
Yes
Blood glucose
<50 Continue stroke response
Identify symptoms Obtain focused history r/t tPA contraindications Alert radiology Call stroke phone within 15 mins and report the following:
Last Known Well Blood glucose Symptoms Focused History Start IV Draw/send labs stat Treat hypoglycemia
per protocol. Reassess for stroke
symptoms. Yes Stroke symptoms still present? Continue to monitor and treat blood glucose No Yes Assess symptoms and history Weakness on one side? Perform non-contrast head CT and CTA head and neck Yes Contra-indication to TPA No Yes Perform non-contrast head CT only No Hemorrhage on
Report all test Report result to
No
Process Map for Acute Stroke
Norton Healthcare
ICU (NH or NBH) General Public EMS ED Wait 29.0 mi n (95%) 3.0 mi n (Medi an) 6.9 mi n (Average) EMS Transfer Pt 12.0 mi n (95%) 0.0 mi n (Median) 4.8 mi n (Average) Transfer Pt 1.08 m in (NAH) 0.5 mi n (N BH) X min (NS H) Y min (NH) = 1 Sign-in = 1 Triage = 3 Stroke Response = 2 CT / CTA = 2 Admin rt-PA Pt Info = 1 Patient Registration S troke O rderEMR System
Records Management Register Pt Pt ID # Pt ID br acelet Add’t Wait 15.8 m in (95%) 2.1 m in (Median) 6.3 m in (Average)Wait on Lab & CT Results Wai t on Either: 56.9 m in (95%) 12.4 m in (Medi an) 19.3 m in (Average) N = 44 (i ncl udes 3 no wai ts)
W ait on Lab Result: 56.9 m in (95%) 32.4 m in (Medi an) 35.8 m in (Average) N = 8 Wait on CT Resul ts 35.5 m in (95%) 10.5 m in (Medi an) 17.1 m in (Average) N = 33 Transfer Pt 1.08 m in (NAH) 0.5 min (N BH) X min (NS H) Y min (NH) Wait on Tx Decision
(i ncludes CTA W ait) 60.7 min (95%) 46.7 m in (Median) 51.2 m in (Av er age) N = 9 (Total rt -PA Pts in S tudy)
CTA TAT: 82.0 min (95%) 61.0 m in (Median) 61.7 m in (Av er age) N = 6 Pure Wait on Tx Decision
(Al l test s i n) 41.7 min (95%) 17.7 m in (Median) 16.7 m in (Av er age) N = 8 (one had MRI) # Adm in = 1 Avg. Ti me = 2.00 min # RN = 1 Avg. Tim e = 2.17 m in # R N = 1 # PCA = 1 # ED MD = 1 Avg. Tim e = 3.33 m in
Call Ahead O rder for CT
# RN = 1 # CT-Tech = 1 CT Avg. Tim e = 2.92 m in CTA Avg. Ti me = 4.83 min
# R N = 2 Avg. Tim e = 4.33 m in
With the exception of the ED Wait queue, 95% wait times are really the maximum non-outlier data point of the set.
2.00 min 2.17 m in 6.9 m in 3.33 min 4.8 m in 1.08 m in 7.75 mi n 6.3 min 1.08 m in 19.3 mi n 4.33 min 51.2 min Expected DTN = 110.24 mi n NVA Tim e = 90.66 m in VA Tim e = 19.58 m in # Admin = 1 CT Or der Lab Order CT Order CTA Or der = 3 Review CT # Radiologist = 1 # ED MD = 1 # Neurologist = 1 CTA Or der (as needed)
rt-PA O rder = 2 rt-PA Decision # ED MD = 1 # Neurologist = 1
Issue O rder for r t-PA to be administered
rt-PA Door-to-Needle (DTN) Process
Current State: Data Range from 12/01/11 to 03/31/12
For N = 4 (4 of 8 had rt-PA) Draw to Lab: 23.2 m in (Av er age) CBC: 5.3 m in (Av er age) INR: 20 m in (Av er age) CM P: 25.8 m in (Average)
Post CT W ait for CTA O rder: 87.8 m in (95%) 19.4 min (Median) 36.6 min (Average) N = 6
200
150
100
D
T
N
T
im
e
(
m
in
)
_
X=59.3
UCL=100.5
Pre-Project
Project
1Identifying Waste in a Process
Key Points for a PI Project
•
Garner executive support and build the team
•
Scoping – SMART goals, Beginning/end
•
Leverage literature for understanding, not to simply copy
Executive Champion
Based on this problem who would you think would provide the most
appropriate executive support for the project?
Team
Scope
How would you scope this project?
What would you include in the charter?
Where should the project begin and end?
Best Practices to guide work
How do you think you should identify the best practices to guide the
work of the team?
Key Process Outcome Metrics
KPOMS
What would be the key outcomes desired for this project?
What data should you collect?
Communication
When is it important to communicate the project work?
What should you communicate?
How should you communicate?
Root Cause
How would you get at the root cause of a problem?
The Solution
How would you pick the best solution?
Sustaining the improvement
How do you make sure the improvement is sustained over time?
