Lean Approaches for System Transformation in Endoscopy

Transcription

1 Lean Approaches for System Transformation in Endoscopy 2016 National Health Leadership Conference June 7, 2016 Jane Curtis Jonathon Drabik Denis Fortier Dawn Ridd Eileen Vodden

2 Starting a Movement

3 Lean Approaches for System Transformation in Endoscopy Workshop Goals: To understand approaches for system transformation To gain detailed knowledge about the implementation of a region wide endoscopy central referral program To provide tangible ideas and strategies for achieving system change.

4 Who Are We? Southern Health-Santé Sud is a regional health authority in the southern portion of the province of Manitoba. 27,000 km 2 Population 195,000

5 3700 colonoscopies annually lengthy wait times limited wait time reporting or tracking limited referral prioritization for urgency backlog of 250 patients

6 What Did We Achieve? Reduced wait times between 55% to 80% Standardized and streamlined the processes across all endoscopy sites Clear referral guidelines for primary care Ability to track wait times and patient referrals

7 The Five Principles of Lean 1. Voice of the Customer (VOC) 5. Pursue Excellence 2. Understand your Process 4. Establish Pull 3. Create Flow

8 The Eight Wastes Defects Overproduction Waiting Non-Utilized Talent Transportation Inventory Motion Extra Processing

9 DMAIC Road Map Pre-requisite: a process There is an existing process that likely contains root cause that materially affect customers (patients) and/or the business (system) internally Define Measure Analyze Improve Control Define the problem properly so that you solve the right problem Measure the as-is process in order to characterize the problem and to enable measurement of improvement Hunt for clues using analysis and experience Test hypotheses and get a repeatable solution Keep new process locked in

10 Southern Health-Santé Sud Colonoscopy Project D M Aim: Primary Care Referral to Colonoscopy in 13 Days Urgent/27 Days Semi-Urgent Measure: Referral Received at Central Referral Office to Colonoscopy Understand the System Baseline data 5 surgery sites Process Mapping Primary Care referral data A Understand Best Practice Engage Stakeholders Determine standards for Colorectal pathways Pre-Op Anaesthesia Screening & surveillance Surgeon/endoscopists Hospital site leads/slating office Anesthesiologists Primary Care leads Navigators I Address System Gaps Improve New Gastrointestinal standard referral form New central booking process Out the Door in 24 same day referrals Pathology Cancer Biopsy Results Sticker Project Implement best practices Phased in roll out Primary Care Education Workshops Education sessions with site slating and surgeons offices EMR integration C Central Referral 2 Wks U/4wks SU from referral received to scope date 100% compliance (all referrals received at Central Office)

11 Southern Health-Santé Sud Colonoscopy Project D Aim: Primary Care Referral to Colonoscopy in 13 Days Urgent/27 Days Semi-Urgent Measure: Referral Received at Central Referral Office to Colonoscopy

12 Southern Health-Santé Sud Colonoscopy Project D M Aim: Primary Care Referral to Colonoscopy in 13 Days Urgent/27 Days Semi-Urgent Measure: Referral Received at Central Referral Office to Colonoscopy Understand the System 1. Determine key measurement points & targets

13 Southern Health-Santé Sud Colonoscopy Project D M Aim: Primary Care Referral to Colonoscopy in 13 Days Urgent/27 Days Semi-Urgent Measure: Referral Received at Central Referral Office to Colonoscopy Understand the System 1. Determine key measurement points & targets 2. Collect baseline data: -Audited charts at each site -Key findings were: -Wait time from referral to decision to treat not collected -Wait time from decision to treat to procedure - over target at all sites -Non standard processes, significant variation

14 Southern Health-Santé Sud Colonoscopy Project D M Aim: Primary Care Referral to Colonoscopy in 13 Days Urgent/27 Days Semi-Urgent Measure: Referral Received at Central Referral Office to Colonoscopy Understand the System A Understand Best Practice Engage Stakeholders Stakeholders Primary Care Practitioners Primary Care Clinic Staff Surgeons/Endoscopists Anesthesiologists Hospitals Slating Surgeon Clinic Staff Electronic Medical Records Referral & Pre-Op Guidelines Sedation Guidelines Colonoscopy Prioritizations Colonoscopy Screening & Surveillance Direct to Scope Recommendations

15 Southern Health-Santé Sud Colonoscopy Project D M A Aim: Primary Care Referral to Colonoscopy in 13 Days Urgent/27 Days Semi-Urgent Measure: Referral Received at Central Referral Office to Colonoscopy Understand the System Understand Best Practice Engage Stakeholders I Address System Gaps Future State Process Map

16 Central Referral Process Establish Central Referral Office Standard referral form Input from stakeholders Used for all gastrointestinal endoscopy consultation/referrals Available in paper and EMR Includes pre-op history & current medications Includes ASA classification Patient Preference Next available appointment or preferred site/specialist Link to Cancer Navigation Services Direct to scope default option

17 Central Referral Process Reasons for Referral Indicators align with the In Sixty Colorectal Pathway Targets for Urgent/Semi Urgent Single referral process for primary care This referral form replaces the following forms/documents: referral letter pre-operative history form Cancer Navigation referral

18 Pathology Sticker Project Suspicious for Cancer Sticker Project Endoscopists place a pre-printed green sticker Suspicious for Cancer on the lab requisition of colorectal specimens with appearance compatible with invasive cancer Lab - completes testing & reports results in 7 days Suspicious for Cancer Baseline wait time 14 days 88% of colorectal samples with the sticker meet the 7 day target wait time

19 Southern Health-Santé Sud Colonoscopy Project D M A Aim: Primary Care Referral to Colonoscopy in 13 Days Urgent/27 Days Semi-Urgent Measure: Referral Received at Central Referral Office to Colonoscopy Understand the System Understand Best Practice Engage Stakeholders I Address System Gaps Improve

20 System Education: Phased in roll out to 28 primary care clinics: Offered in person & via telehealth in each sector Clinical case study session for primary care providers Training about new process to clinic office staff Intensive new process training Each hospital s slating staff & managers Each surgeon s clinic staff

21 Out the Door in 24 Primary Care Practice Improvement

22 Four Super Fast Fixes to Quick Referrals: Stop Batching

23 Four Super Fast Fixes to Quick Referrals: Eliminate Old Forms

24 Four Super Fast Fixes to Quick Referrals: Don t Send Incomplete Forms There were 50 defective referrals over 3 weeks or an average of defects/week. The median wait time to complete these referrals was 8 days.

25 Four Super Fast Fixes to Quick Referrals: Send to the Right Person/Place

26 Out the Door in 24 Improve Data Baseline data ranged from 37 to 2 days

27 Southern Health-Santé Sud Colonoscopy Project D M A Aim: Primary Care Referral to Colonoscopy in 13 Days Urgent/27 Days Semi-Urgent Measure: Referral Received at Central Referral Office to Colonoscopy Understand the System Understand Best Practice Engage Stakeholders I Address System Gaps Improve C Central Referral

28 All Site Data Comparison Baseline vs Central Referral Before After Wait time for all cases at the 90 th percentile has dropped from days to 57.2 days Standard Deviation decrease (from 49.6 to 20.0) indicates a more stable and predictable process.

29 Wait Time to Colonoscopy Target 14 days Target 28 days Target 4 months

30 Central Referral Wait Times Colonoscopy to Bowel Surgery Central Referral Patients Not Central Referral Patients Patients who went through Central Referral for Colonoscopy also had a shorter wait time to Bowel Surgery compared to non Central Referral patients.

31 Project Savings Overall Savings Staff Time Available to Reinvest 1330 Hours Patient Wait Days Reduced (increase access to services) 462,240 Days Operational Costs Reduced $504, Site Improvements Site Turn Around Time (TAT) Referral to Colonoscopy Procedure Baseline 90%ile Post Improvement 90%ile % Improvement Carman Hospital % Boundary Trails Health Centre % Portage Hospital % Bethesda/Ste Anne Hospital %

32 Central Referral Database Controlling the Improvement

33 Days Days 29-Sep-15 Days Days 5-Nov-14 9-Dec Mar Nov Nov-14 4-Dec Dec Dec Jan Jan Jan Jan-15 3-Feb Feb Feb Feb Feb Feb-15 6-Mar Mar Mar Nov-14 2-Dec-14 6-Jan Jan Jan Feb-15 6-Mar Nov Nov-14 4-Dec Dec Dec Dec Jan Jan Jan Jan Jan-15 2-Feb-15 6-Feb Feb Feb Feb Feb Feb Feb Mar Mar Mar-15 TAT referral to scope REFERRAL DATE from Sep 01,2014 until Sep 01,2015; Facility: Boundary Trails Wait Time Reports URGENT SEMI-URGENT Dec Jan Jan Feb-15 9-Mar Mar-15 Date of Referral Date of Referral ELECTIVE/CONSULTATION TOTAL Date of Referral Date of Referral

34 Southern Health-Santé Sud Colonoscopy Project D M Aim: Primary Care Referral to Colonoscopy in 13 Days Urgent/27 Days Semi-Urgent Measure: Referral Received at Central Referral Office to Colonoscopy Understand the System Baseline data 5 surgery sites Process Mapping PC referral data A Understand Best Practice Engage Stakeholders Determine standards for Colorectal pathways Pre-Op Anaesthesia Screening & surveillance Surgeon/endoscopists Hospital site leads/slating office Anesthesiologists Primary Care leads Navigators I Address System Gaps Improve New Gastrointestinal standard referral form New central booking process Implement best practices Phased in roll out PC Education Workshops Education sessions with site slating and surgeons offices EMR integration C Central Referral 2 Wks U/4wks SU from referral received to scope date 100% compliance (all referrals received at Central Office)

35 Breast Assessment Centre Case Study Open your workbooks Have one member of your group agree to report back on your work Have one member of your group read each section of the case study out loud. Work through the questions to complete your System Transformation Template

36 Define & Measure

37 Analyze

38 Improve

39 Control

40 Breast Health Assessment Centre Aim: Referral to Biopsy Appointment in 7 Days Measure: Referral Received to Biopsy Appointment Understand the System Stakeholders 28 Primary Care Clinics; 2 Mammography Sites Process Mapping 6 months Baseline Data Incorporate Best Practice BI-RADS Coding Breast Cancer Pathway Breast Direct Referral Engage Stakeholders Primary Care Providers & Clinic Staff Radiologists, Technicians & Staff Breast Assessment Clinic Staff Address System Gaps Standard Referral Form Implement BI-RADS Coding for Triaging Scheduling Template Improve Primary Care Education to improve referral defects Remove old forms from Referring Offices & implement new form Educate stakeholders on new process and breast cancer pathway & targets Implement wait time data tracking Regional report (quarterly) of breast assessment wait times Target Achieved 7 days referral received to appointment date 100% defect free

41 LEADS Change L Self Motivated Leaders Physician Champion E Engage Others Stakeholder Engagement A Achieve Results Data, Goals & Targets D Develop Coalitions Partnership & Feedback S System Transformation Changing Culture

42 Questions? Stay the Course!