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01/19/2012 05:10 PM
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263662Joe Kane
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I am a Lean Consultant now on a hospital assignment. Our Kaizen Team has been asked to work on reducing avoidable days for their top 10 Medicare DRG's. Does anyone have any practical or case experience reducing Length Of Stay kaizen activities? If so, I would appreciate hearing from you.
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01/20/2012 12:25 PM
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Joe,
Let me suggest that going after LOS stay with a Kaizen is kind of like going after world hunger with a Kaizen. It's a worthy cause and nobody's going to argue that it's the right thing to do, but it's just a bit too big and ugly. How long a patient stays in a hospital is a process that's made up of many sub-processes. We've had much more success in going after those sub-processes one at a time. Sure, it's not as flashy as going right for LOS, but in the long run, more people are learning about Lean and how to use it to improve the whole hospital.
Tom
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01/20/2012 12:25 PM
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Hi Joe,
We have been working on LOS and excessdays for over a year now and have been able to shave off 0.5 days. We found two ways to do this. We increased everyones awareness about LOS by using visual management tools. We have a daily contrrol board on the unit (fully HIPPA compliant). We use color coded magnets to identify all kinds of care issues but mainly LOS. Any staff member can look at the board and know how long a patient has been in the hosptial - this includes physicians.
The other tool is the white board in the patient room. Each staff nurses is now writting a possible date of discharge on the white board and holding a conversation with the patient and family regarding discharge upon admission. This sets some expectations and changes the patient and family perception about how long the patient will be in the hosptial. In a years time we have only had one complaint from a patient/family about the date. The physicians are supportive because it lets them know the plan has been started and they can then continue the conversation.
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01/23/2012 11:45 AM
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263662Joe Kane
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Tom, many thanks for your reply. As a 26 year manager with Toyota, 15 of which have been spent in Lean Deployment, I agree with your diagnosis. The hospital leadership, new to lean, set out on this priority project prior to my consult arrival. We are in the Define stage just finishing our initial data collection and SIPOC-R of Discharge Planning. As we move forward we've divided the project into 4 smaller kaizen projects hoping that our leadership team will see the large scope and all the issues around LOS. I am going to count on letting the data, supply chain map and issues list do the talking for this concern when we gather at next leadership project update meeting. I do appreciate your insights and thinking with me about the challenges we face. Joe
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01/23/2012 11:45 AM
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263662Joe Kane
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Sherry, thanks for your reply. All very helpful. I learned yesterday that a patient room white board kaizen had been implemented a few weeks ago. I will be going to the "gemba" next week to see it with our project team. The larger PCB is also worth considering for the unit level. Glad to hear the physicians are supportive of these countermeasures, as this is one of our fears. We're still in the Plan (Define) phase, so I do have some work ahead before Act, but again, thanks for these successful ideas. Joe
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01/23/2012 11:45 AM
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I think it will be important to study the "as is" state first. This means you have to go see the patient transformation. From there the problems will be seen and you will be able to determine the best approach to tackling the problems one at a time to reduce overall length of stay.
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01/23/2012 11:45 AM
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I agree with the earlier comment about not trying to solve world hunger or boil the ocean.
Look for the main contributors to why LOS is longer than it needs to be medically. Often, this is due to the discharge process, which is still a big project to tackle.
If you're going to use the weeklong improvement event methodology, make sure you break the problem up into a small enough piece. Then, identify things through the staff that can be done on a more continuous kaizen basis.
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01/24/2012 12:39 PM
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263662Joe Kane
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Mark, thanks, I am finding your book very helpful. It is my goal to be able to have our teams which are now 4 sub-teams work on there smaller problem scopes. It appears the Discharge Planning team will cross over into Patient Family, Community and Utilization sub-teams. I am hoping they will accept the week long Kaizen Event approach. If I were to do it again, I would insist on a smaller scope for their first project. This way they all learn and gain a deeper appreciation of the tools and problem solving with out the complexity and pressure of time. Let's stay in touch. Joe
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01/24/2012 12:39 PM
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263662Joe Kane
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Leslie, thanks for your note. This "go to the gemba" stage of the Discharge Planning Process is coming up as soon as we finish our SIPOC-R as-is. I am sure it will be very telling. Ideas are always welcome. Joe
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01/30/2012 03:35 PM
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Hi Joe,
Like others have said, reducing LOS is a multi-factorial challenge. I have learned that to truly manage and sustain a LOS reduction requires a journey of continuous improvement (CI) approach rather than a few projects. A few things we did to sustain a ALOS reduction of .75 to 1 day and reduced excess day by 45% overall was:
1. Identified DRG opportunities
2. Created and shared monthly trending reports by MD and unit for ALOS to GMLOS with excess days opportunities. Discussed at monthly nursing meetings and MD meetings
3. Implemented daily (every pt every day) Interdisciplinary Care Rounds focused on moving the pt forward in the continuum, identifying discharge barriers earlier on, and planning today for tomorrow's discharges. Attended by primary nurse, case management, dietary, social work and other ancillaries as needed.
4. Utilizing pt white board to set expectations for discharge with pt and family.
5. Established a discharge by noon goal.
6. CI for discharge barriers
7. Working/collaborating with discharge facilities to streamline placement (limited beds in the community).
This requires strong commitment from physicians, leadership and nursing, along with communication, communication...
Thx! Jeff
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01/31/2012 01:48 PM
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263662Joe Kane
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Jeff, thanks for your input to this challenging project. By the way, congratulations on the .75 to 1 day reduction in your LOS and other LOS improvements. We're looking for 1.44 ave days reduction in LOS and it seems pretty daunting just now. Interesting we just completed two significant studies comparing our 2010 vs 2011 LOS trends by DRG and ICD9 to capture as much understanding of the contributing DRG's and their correlations as possible. In our meeting today, our leadership team decided not to map the process of a specific DRG or ICD9. Rather we will start by mapping the "As Is" of a most standard process that allows us to "see" the elements and issues of this supply chain in the swim lane map from Admission to Discharge, using the information from our SIPOC-R work from our subgroup teams as a foundation for this next step. If we do this right we should see many of the items you have uncovered in your project listed in items 2-7, most likely even more. As you suggested key to our success will be our physicians and nurses, so our team is now working on two VOC survey's and a strategy of communication and engagement with them in our mapping process to gain their support. This will be a huge factor in determining progress and achievement of our LOS reduction targets. I do hope we can continue sharing as this project is a major Hoshin item for the hospital leadership this year, so failure is not an option... Joe
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01/31/2012 01:48 PM
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263662Joe Kane
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Mark, I wanted to follow-up on my LOS project with you and ask a question regarding Value Stream Mapping. Our LOS Kaizen team will be starting their process mapping tomorrow. The team decided to map the general process from Admit to Discharge so we could see the "as is" flow first, then determine waste then "to be" state map. Can you advise the best mapping type for our team. At Toyota I always used a swim lane map starting with a big paper process then on to visio when we we're finished the drafting. I am not really sure if this approach is too much detail for them, unless I break the mapping into logical admit to discharge sections. Your book provides a very high level of advice. LEI and Cindy Jimmerson use a kind of picture map not a swim lane map. It seems as if for a hospital it might be best to use the combination of a process map simple flow, and add small boxed sections, with data points to determine Non-value from value, waste, issues.
Your thoughts. I am having second thoughts on my approach in this final hour of starting our mapping process tomorrow afternoon. Thanks for your help.
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02/03/2012 10:20 AM
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Joe - this reply is too late for your event this week (I didn't get notified of a reply to this thread until today's weekly update).
I've used a combination of mapping styles. If looking at the end-to-end flow or something across departments, I'll use a high level VSM - mainly to have everybody map and see the big picture and the fumbled handoffs across departments.
Then, it's helpful to do more detailed process maps or swim lane diagrams to take a deeper dive into the process as needed.
Finding data is often a real challenge in healthcare mapping.
How did it go for you this week?
Mark
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02/03/2012 01:34 PM
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jhargraveJeremiah Hargrave
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Hi Joe,
I realize this will get to you too late for your initial mapping but thought that I would share some of our VSM experience. We have been successful using multiple VSM methods (simple process flow, very detailed process flow and swim lanes). Our preferred method for initial mapping is a swim lane map (U of T process). As process steps move from lane to lane, hand-offs of patients and information are very visible. We haven't overwhelmed anyone, or should I say nobody has said that they were overwhelmed! The greatest benefit of the VSM activities for us has been getting the team to "see" the process together, learn together and break down the barriers between different areas.
Every tool has been effective in helping the team identify waste and potential improvement opportunities as well as aiding in the problem breakdown/scoping.
Thanks,
Jeremiah
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02/06/2012 11:21 AM
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263662Joe Kane
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Mark, thanks for your email. Even if late it helps. I will try to attach a few pics of my map to give you a view of our team's work. I decided to go with the VSM and swim lane map. We pioneered this at The University of Toyota after working with our Toyota NA Logistics Group in KY. I feel fortunate that we were able to narrow down the swim lane groups from 15 in the SIPOC-R to 7 and 4 high level steps, and kept the business steps it at a level 2 to avoid too much detail. We've spent 6 hours with a cross functional team of representatives from each of the groups, except our Physicians. We have invited the Physicians into the process for viewing next Friday once we have a near completed Post it Note map. You will see I use pink Post-it Notes for Issues which there are many. We will be working next week at our 2 hr daily meetings M-W to reconfirm each of these issues and group them into themes, load them in excel and agree to their priority. We are also nearing the point where we need to take our VOC data from the Nurses and Physicians into account confirming issues. Also, I going to break the map into small process sections and assign work groups to go onto the hospital floor (gemba) to confirm that our processes mapped in the room are accurate. What is a bit challenging in the VSM is documenting the process metrics. Cycle time, Vol etc. So any advice on this aspect of the mapping process would be helpful. Once we have a first hand view of the process by smaller section and there metrics we can better evaluate Non Value vs Value in the "As Is" map. We hope from this to move to our Chart review and walk through a DRG chart (say DRG 690) a high Length of Stay DRG to validate the waste. My VP wants this to move quickly since our goal is reducing length of stay by 1.44 days and $5.0M in related cost reductions in 2012. Needless to say getting to the "Future State Map" is a high priority here, making my task a challenge. Your continued advice is greatly appreciated. I appears my pics will have to come under separate cover. Sorry to ramble. Regards, Joe
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02/06/2012 11:21 AM
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263662Joe Kane
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Jeremiah, thanks for your note. I am trying to send you and Mark a few photos of the map however they won't upload on this blog. The VSM is going well. I am almost finished drafting the "As Is" process. It is working as you describe. One key question. Where do you display the cycle times and other process metrics once they are collected. In Cindy J's map method the map space allows for the data collection box below the process step. A VSM swim lane map takes up most of the space on the 8.5x11 or the plot. If I can solve for this we would have a great mapping solution, maybe even a new mapping book.. Thanks for all your help. Joe
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02/08/2012 10:48 AM
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jhargraveJeremiah Hargrave
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Hi Joe,
I place a high level timeline across the top of the map to show the big buckets of time and provide a sense of overall process length. I'll put cycle time and other data that I might have right on the map in some form of a text box or call-out. This is usually enough information to help the team break the value stream into sections. As Mark suggests, after the team sees the big picture we will take a deeper dive into processes and time work elements and look for more specific data.
Jeremiah
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02/19/2012 07:51 PM
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do you have specific line managers / frontline workers who are responsible for LOS problem solving day to day?
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