Groupe-conseil stratégie et performance ISO 9001:2000 Lean Simulation Medical Records Department RCGT Hospital November 22, 2011
Federal Context t Deficit Reduction Action Plan Find $4 billion in permanent annual savings by 2014-2015 The review will place particular emphasis on generating savings from operating expenses and improving productivity, while also examining the relevance and effectiveness of programs. Being more productive means working better, not longer! 2
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Workshop op Objectives es Simulate the experience of a Lean transformation From a current process to a Lean process Based on an actual project Present the principles behind the Lean approach Demonstrate how to apply Lean concepts in the federal public service 4
Agenda Session 1 (10:45 to 12:00 p.m.) 10:45 Introduction 11:00 Simulation instructions 11:15 Current process simulation 12:00 Lunch Session 2 (13:30 to 14:30 p.m.) 1:30 Review of results 1:45 Instructions for the Lean simulation 2:00 Lean simulation 2:30 Break Session 3 (15:00 to 16:00 p.m.) 3:30 3:45 4:00 Review of results - Lean simulation Lean concepts End of workshop and draw 5
Our team Ottawa team François Vanier Melanie Travers Daniel Dubé Marco Perron Michelle Nadeau Montreal team David Mascolo Richard Tordjaman Marie-Christine Gentès Line Provencher 6
Current Process Simulation 7
Simulation The simulation re-enacts a typical 24-hour day in the Medical Records Department, within a period of 30 minutes The Medical Records Department ensures the completeness and quality of medical information Provides patient files to the various hospital services and in particular: ER services Outpatient clinics Physicians These files are then returned to the Medical Records Department at the end of a patient s stay 8
Simulated processes Five different processes will be observed during the simulation: Physician s consultation: The physician requests medical records for consultation; STAT requests: Arise due to the admission of patients in the emergency room (ER); Outpatient clinics: The preparation of outpatient clinics for the following day s appointments; t Coding: The validation and coding of medical procedures and data entry into the system; and Transfers of patient records: The scheduled tours to collect and deliver the medical records to the various departments 9
Administrative Agents B Layout Doctors Lounge Receptionist Internal Courier Medical Coding Specialists Administrative Agents A Medical Records Shelving Unit 10
Dr. Raymond Process Involved involved in this process: in: Physician s Physician s consultation consultation Internal Courier Doctors Lounge Request patient files Receptionist Admi nistrative Ag gents B Administrative Agents A Medic cal Codin ng Specia lists Medical Records Shelving Unit 11
Receptionist Involved Processes in these involved processes: in: Physician s consultation STAT requests Internal Courier Doctors Lounge Provide files Receptionist Deposit file loan forms Admi nistrative Ag gents B Administrative Agents A Medic cal Codin ng Specia lists Medical Records Shelving Unit 12
Internal Courier Process Involved involved this process: in: Transfers of patient records Deliver files to other departments Internal Courier Doctors Lounge Retrieve files from any location Receptionist Admi nistrative Ag gents B Provide files Administrative Agents A Medic cal Codin ng Specia lists Medical Records Shelving Unit 13
Medical Coding Specialists Involved Process in involved this process: in: Coding Coding Internal Courier Doctors Lounge Receptionist Adm ministrativ ve Agents B Administrative Agents A Provide requisition form Deposit complete files in To be Filed pile Med dical Cod ding Speci ialists Medical Records Shelving Unit 14 Enter procedures into system Verify signatures Complete file requisition forms
Admin Agents A Process involved in: Supporting Supporting the other other processes processes Internal Courier Doctors Lounge Receptionist Admin nistrative Age ents B Sort loose sheets Retrieve and file records Administrative Agents A Medic cal Codin ng Specia lists Medical Records Shelving Unit 15
Admin Agents B Process Involved involved these processes: in: Outpatients clinics Internal Courier Doctors Lounge Receptionist Admin nistrative Age ents B Sort files Place on clinic pile Administrative Agents A Medic cal Codin ng Specia lists Medical Records Shelving Unit 16
Objective e of the game Prepare the files for the outpatient clinics of the next day in the 30 minute time period provided, while responding to various requests from other services / departments. 17
Rules uesof the game Players must complete their tasks, following the instructions provided on their work station STAT requests should be given priority over other requests from other services You may retrieve files from all work stations within the Medical Records Department, except for the Internal Courier s station, that is considered to be outside the Records Department You cannot hide files or refuse to remit files to a participant who requests ests a file 18
Instructions s for the observerse s Your role is to observe the problems in the simulated process Complete the exercise provided as a team (one team per table) : 1. Identify wastes 2. Discuss solutions for eliminating the wastes Each table must identify and note down ONE recommendation for improving the process 19
Review of results Current Process Simulation
Your thoughts? ts 21
Typical feedback It seems we are always looking for files The administrative agents A are so busy that they create a backlog The administrative agents B waste effort, since others come to take their files which are needed elsewhere We step on each others toes at the Medical Records Shelving Unit, as there are too many people searching for files at the same time It takes a long time to receive requested files The division of work between positions is inequitable We have difficulty finding some files 22
Your recommendations e o to improve the process Most common recommendations: Create a system to track the files within the organisation Add resources to handle the volume Redistribute tasks between the staff Provide rollerblades to the internal courier Promote versatility and mutual aid among the team 23
The Lean way aytoa analyse aysethis... Waste identification Min. lost Root causes Lost time searching for files in piles Lost time waiting for files (coding specialists) Lost time checking for missing signatures Lost time moving from table to table Lost time sorting files in numerical order in a pile Lost time finding the right sequence when sorting files Lost time waiting at the Medical Record Shelving Unit 35 Lack of capacity or flexibility at the Admin. Agent A workstation 10 (bottleneck) 10 5 5 5 5 Bad timing to retrieve the next day s outpatient clinic files Doctor s files are not returned to filing Unreasonable amount of files requested by the coding specialists 24
Main areas for improvement po e As much as possible, ensure that files remain in the medical records shelving unit, so as to limit the time and effort spent looking for files. To do this, one should: Retrieve files only when needed (as close as possible to the moment when the file is required) Aim to retrieve, return, sort and file records in the medical records shelving unit within one working day Return all files to the medical records shelving unit every evening Wait for a file to be returned and sorted before transferring it to outpatient clinics, so as to limit the time wasted on retrieving files for other participants. 25
Changes brought to the processes New management rules The physician now has to return files after he / she has consulted them The outpatient clinics will be prepared only at the end of the day (at the 21st minute of the game) Implementation of tools to manage the replenishment of files (Kanban) Medical coding specialists cannot have more than 20 files on their desk at all times and cannot complete and requisition more than 5 files at a time (controlled through the use of a sorter with 5 slots) Implementation of visual management tools File requisitions are placed in a basket for this purpose A colour chart helps to speed up the process of sorting The records to file will be sorted into 2 piles (0 to 399 and 400 to 799) 26
Changes brought to the processes (cont d) Implementation of a work cell 1. Each agent has one primary and one secondary task, which can be to sort, file or retrieve files. 2. The new layout and management rules are presented in the plan below 27
Instructions s for observers e s Your role is to observe the impact of the changes made to the processes With the same team, complete the exercise on performance indicators In the last 10 minutes,,you should only be observing the simulation 28
Tools in Place Workcell Within a process, strategic grouping g of various resources involved in the process activities Completion of most process steps within the workcell Example: Operational Arrangement Workcell Arrangement A C i A A A A i B B B C C C C i D D D D 29
Tools in Place Kanban Signals that authorize and give instructions on when to carry out an activity within a system Each empty slot means that a new file request must be made The number of chairs sets the optimal number of users in the waiting room 30
Tools in Place Visual management Tools that enable the rapid identification of anomalies and contribute to the management of activities on a daily basis Use visual signals such as: Colour coding Containers: Baskets, carts, etc Tables Diagrams 31
Lean Method Principles 32
The Foundations o of Lean Thinking Define value Map the value stream Create flow The Lean management philosophy is at the heart of Lean thinking The organization must use a long- term strategy and focus on overall objectives The sum of local successes does not guarantee overall success Establish pull systems Strive for Perfection Lean thinking encompasses five principles that improve product and service quality by optimizing the flow and reducing waste 33
A Few Definitions Define Value Value-added activities (VA) Activities that transform or change a product or service in such a way that the client perceives value Non-value-added activities (NVA) Activities that do not add any value to a product or service as perceived by the client, but that take up time, resources and space NVA activities are a waste that increase time spent in a process, resulting in a higher cycle time 34
Our Understanding of the Process Map the value stream What we think it is What it really is What it should be 35
Main Forms of Waste Insufficient use of talent & creativity 7 8 Over Production 1 2 Waiting Defects & rework 3 Motion 6 5 Inventory 4 Transportation ti Overprocessing Waste What is it? Examples Over production X Y Produce or process more than what is really needed and before it is requested Producing reports that are not read Producing a 30-page report when a two-pager would be enough Balancing to the penny Waiting Amount of time during which there is no work being done on the service Waiting for information or clarifications from another department Waiting for a manager s approval System downtime or slow system response Transportation and Employee or information Documents (e.g., invoices) handling travel between the various activities travelling through different departments for approval or validation purposes Sending an email and copying ( cc ) the entire organization 36
Main Forms of Waste Insufficient use of talent & creativity 7 8 Over Production 1 2 Waiting Defects & rework 3 Motion 6 5 Inventory 4 Transportation ti Overprocessing Waste What is it? Examples Over-processing Inventory Any work or activity that does not add value Any task or material in excess of the client s needs Double validation (e.g., a purchase order approved by both the manager and accounting) Entering the same information into several systems Too many archives (electronic and paper) Piles on desks (invoices, requests, etc.) Motion Defects and rework Waste? Ancillary Activity Added Value Any staff or equipment motion that does not add value to the service Any activity that must be done again to meet the client s expectations 37 Document searches Poor workstation set up (printer far away) Continually changing the screen view to perform a task Data entry errors that show up in the following work step Starting a task over Client dissatisfaction
The Eighth Form of Waste Insufficient i use of talent t and creativity it Staff very often have all the necessary skills to solve productivity it problems. By not asking them questions, organizations deprive themselves of a great source of creativity and create waste Results = the quality of the solution X buy-in from staff 38
What Must Be Done Create flow Understanding and measuring the current state of each line and service (value stream) Analyzing all activities to see if they generate waste or if they really have added value Improving value by eliminating waste and ensuring work flow The client must be able to pull on the value stream 39
Foundations of a Value-added Establish pull Organization systems Time it takes for information and material to go through your value stream Product or Service Time it takes for information and material to go through your value stream Poor Training Poor Equipment Poor Work Method Poor Management Product or Service To have added value, you must identify and eliminate the obstacles that obstruct its path You must lower the water level l Poor Training Poor Equipment Poor Work Method Poor Management Your value stream must flow harmoniously, like a river, from order reception to client service delivery, after having gone through suppliers and subcontractors -40-
Cycle of continuous improvement po e -PDSA Plan Do Current situation Current processes Study Put in practice Issue identification Study the changes Objectives Do the changes meet the objectives? Yes, it s time to find another department to optimise! Future state and potential solutions Ideal process Act No Apply corrective actions on a continuous basis
Cycle of continuous improvement PDSA (cont d) Phase I Phase II Identify, measure, analyse and Plan improve the current situation Do put in practice 1. Objectives and project management 2. Present Lean simulation to Steering Committee 3. Establish the context of the departments concerned 4. Change management strategy and communication plan Issue identification Current Situation Objectives Future state t and potential ti solutions 5. Lean simulation and training for project teams on the data collection tools 6. Interviews with key staff and targeted field observation 7. Performance analysis with a comparison group 8. Support project teams in the data collection 9. Presentation of data collected to the Steering Committee and development of Kaizen charters 10.Kaizen blitz and a general workshop for all administrative services 11 11.Change management and communication activities 12. Implement action plan and performance management and improvement Direct supervision of the processus Daily supervision Study Daily monitoring meeting Dashboard and visual controls study the changes 13. Assist the team in the implementation of performance management and improvement Act apply corrective actions on a continuous basis 14. Assist the team in corrective actions to be applied to processes
A Tall Order You have to increase capacity reduce cycle time tackle quality the first time around reduce your costs eliminate backlog while continuing to provide the best service to taxpayers!
Take on a Lean Transformation You will get remarkable results 15 to 40 % 25 to 50 % 20 to 60 % 40 to 75 % 10 to 50 % Improve Capacity Address Poor Quality Reduce Costs Improve Productivity Reduce Lead Time Free up resources by eliminating non-value- added tasks Right the first time around No longer need to correct others mistakes No rework Less overtime Less investment in IT to compensate for process weaknesses Process more requests by working more efficiently, not harder No double validations Reduce cycle time for processing applications Reduce backlog 44
Impressive results! Improve productivity, operational capability, competitiveness Improve Capac ity Address Poor Quality Reduce Costs Contact us! Spaces Reduce Office S ctivity Improve Produc Time Reduce Lead T ory Reduce Invento Ottawa team: Optimization Lean Six Sigma Daniel Dubé Senior Director Tel.: 613-236-2211 dube.daniel@rcgt.com Montreal team François Vanier Director Tel. : 613-236-2211 vanier.francois@rcgt.com Line Provencher Senior Director Tel.: 514-390-4181 provencher.line@rcgt.com David Mascolo Manager Tel.: 514-393-4845 mascolo.david@rcgt.com