best interest, for the respiratory therapists to take on so much ... readmissions? And could the cost savings of the ...
Applying Best Practice in COPD
Outcomes • In one year, 2008-2009, UPMC St. Margaret posted a 48% reduction in readmissions for COPD, exceeding its aggressive goal of 40% • An estimated savings to the hospital of over $85,000 • Saved the equivalent of 1.3 FTEs, enabling the hospital to add just one FTE, not the predicted two • Improvements were immediate, and have been sustained
When a chronic condition worsens to the point understanding and mastery of the steps and where the patient needs hospitalization, in all medications to be taken. But even with a perfect likelihood some aspect of care has already fallen protocol, how could they be sure that its benefits through the cracks. Perhaps the diabetic patient would reach every patient, every time? did not receive enough information to manage his condition, or the asthmatic patient didn’t PRHI called on its partner, Healthcare Performance realize that, by skipping her flu shot, she would Partners (HPP) to introduce Lean Healthcare risk not only getting the flu, but serious lung into the implementation. complications. “This is a typical situation, in which Lean works Once stabilized and released from the hospital, so well,” said PRHI’s President Karen Feinstein. the last thing that should happen to those patients “Often, clinicians know ‘what’ to do: Lean prois readmission within days or weeks. Yet too vides the ‘how.’”
often, it happens. And too often, readmission for patients with chronic disease can be considered “failure mode.” It’s bad for patients and expensive for hospitals and the health system.
Why Kaizen ? Ideally, Lean thinking is applied hospital-wide by every person every day. Issues and problems that surface can be dealt with, one by one, collaboratively, in the course of work using Lean thinking, training and tools—even if an issue involves other units. However, when a single, intractable problem is felt across many units, a Kaizen event is often the most efficient means of dealing with it rapidly.
UPMC St. Margaret Hospital in Pittsburgh, under the auspices of the Pittsburgh Regional Health Initiative (PRHI), decided to zero in on one broadly defined condition—chronic obstructive pulmonary disease or COPD—to see whether they could reduce readmissions by 40%. The COPD umbrella generally includes emphysema, COPD readmission was the type of problem that chronic asthma, and chronic bronchitis. About can be untangled in a Kaizen event, a focused, a third of readmissions for COPD occur in dedicated activity to improve one process (or people under 65. “value stream”) quickly. With full support and Applying some relatively simple and well estab- participation by managers and people from every lished clinical guidelines (below) often results affected department and unit, the concentrated in dramatic improvements for patients. The key effort and experimentation can be condensed word is “applying.” The guidelines are known: into a few days. their application is inconsistent.
Initial findings
A team at UPMC St. Margaret began improv- During the initial workshop, the team discovered ing their COPD protocol, with the objective of that most patients did not know how to use their having each patient, by discharge, achieve full inhalers properly– and figuring it out was not as CliniCal guidelines for long term treatment for stable CoPd* 1. Avoidance of risk factors; influenza vaccination 2. Add rapid-acting bronchodilator when indicated
3. Add short- or long-acting bronchodilators and pulmonary rehabilitation 4. Add medium- to high-dose glucocorticosteroids or antibiotics when indicated
5. Add long-term oxygen; consider surgical referral. *Adapted from Global Initiative for COPD, www. goldcopd.org
dedicated activity to improve one process (or “value stream”) quickly. With full support and participation by managers and people from every affected department and unit, the concentrated effort and experimentation can be condensed into a few days. Initial findings
During the initial workshop, the team discovered that most patients did not know how to use their sion was the type of problem that can be untangled in a Kaizen event, a focused, inhalers properly– and figuring it out was not as easy as it sounds. For example, some inhalers need to vity to improve one process (or “value stream”) quickly. With full support and be inhaled quickly, some slowly. Patients were not receiving adequate training on their use. by managers and people from every affected department and unit, the concentrated effort ntation can be condensed into a few days. easy as it sounds. For example, Kaizen event foCus some inhalers need to be inhaled s The Kaizen quickly, some slowly. Patients support goal to reduce CoPd event focused Using inhalers isn’t that simple: some readmission rate by 40%. tial workshop, the team discovered that most patients did not know how to use their were not receiving adequate problem that can be untangled in a Kaizen event, a focused, on eliminating need to be inhaled quickly, some training on their use. erly– and figuring it out was not as easy as it sounds. For example, some inhalers need to waste, so thatslowly. Patient education was falling rocess (or “value stream”) quickly. With full support and between the cracks. respiratory ckly, some slowly. Patients were not receiving adequate training on their use. ple from every affected department and unit, the concentrated effort When they mapped their curtherapists would freed up rt time to transfer Inhale slowly nsed into a few days. rent condition, team members have time to duties and improve patient educate patients, care while minimizing costs. discovered why the current When they mapped their current condition, team members discovered why the current method of and support method of patient education patient education was falling through the cracks: respiratory therapists and nurses each believed the the goal of Using inhalers isn’t that simple: some was falling through the cracks: 3 m discovered that most patients did not know how to use their reducing COPD other was providing it . The team agreed that patient education on issues like inhaler use and smoking eliminated waste using respiratory therapists and nurses need to be inhaled quickly, some readmissions by t was not as easy as it sounds. For example, some inhalers need to slowly. Patient education was falling cessation could best be given by respiratory therapists rather than nurses, and that it would take lean Healthcare tools 40 percent. each believed the other was between the cracks. ients were not receiving adequate training on their use. multiple sessions with each patient to ensure competence. This model would represent a big shift in providing it. The team agreed Inhale quickly traditional roles and responsibilities, but all involved agreed to try it. that patient education on issues Although such a change would be in the patient’s best interest, for the respiratory therapists to take on Continuous flow like inhaler use and smoking apped their current condition, team members discovered why the current method of so much more work would require more personnel. If nothing changed, the team estimated that the cessation could best be given by respiratory Initially, staff members had tried to treat and tion was falling through the cracks: respiratory therapists and nurses each believed the hospital would need to hire two full time employees (FTEs). Using inhalers isn’t that simple: some therapists rather than nurses, and that it would educate three or four patients at one time, in viding it3. The team agreed that patient education on issues like inhaler use and smoking need to be inhaled quickly, some the mistaken belief that it would save time. The take multiple sessions with each patient to ensure This specific issue provided the pivot point for the Kaizen event: Could we find enough time, through slowly. Patient education was falling d best be given by respiratory therapists rather than nurses, and that it would take clinician would start with one patient, then competence. This model would represent a bigLean efficiencies implemented during the event halved the expected num between the cracks. work efficiencies, to halve the required number of new FTEs—hiring one instead of two—and allowing to one. The efficiencies involved doing more work in real time, and stand ons with each patient to ensure competence. This model would represent a big shift in leave to start the next one. If a patient were in shift in traditional roles and responsibilities, but Inhale quickly the respiratory therapists to educate COPD patients, helping to reduce readmissions? And could the cost and processes among respiratory therapists. Here is a summary: es and responsibilities, but all involved agreed to try it. isolation, the therapist moving from patient to all involved agreed to try it. savings of the improvements cover the cost of the FTE, making the change revenue‐neutral? Continuous flow. Initially, staff members had tried to treat and educ patient had to wash, gown and glove repeatedly. Using inhalers a change would be in the patient’s best interest, for the respiratory therapists to take on Although such a change would be in the patient’s one time, in the mistaken belief that it would save time. The clinician ondition, team members discovered why the current method of The travel time between patients added up. Not work would require more personnel. If nothing changed, the team estimated that the best interest, for the respiratory therapists to then leave to start the next one. If a patient were in isolation, the the isn’t that gh the cracks: respiratory therapists and nurses each believed the every patient received all necessary information. d need to hire two full time employees (FTEs). take on so much more work would require patient had to wash, gown and glove repeatedly. The travel time bet greed that patient education on issues like inhaler use and smoking chart). Not every patient received all necessary information. simple. Some more personnel. If nothingThe Kaizen event focused on eliminating waste, changed, the team Here was a big and counter intuitive discovery: piratory therapists rather than nurses, and that it would take sue provided the pivot point for the Kaizen event: Could we find enough time, through not only did batching treatments fail to save estimated that the hospitalso that respiratory therapists would have time to would need to hire Here was a big and counterintuitive discovery: not only did batching need to be ies, to halve the required number of new FTEs—hiring one instead of two—and allowing to ensure competence. This model would represent a big shift in denied the therapist time to observe and evaluate the patient’s unde educate patients, and support the goal of time, it denied the therapist time to observe and two full time employees (FTEs). reducing COPD readmissions by 40% the therapy. y therapists to educate COPD patients, helping to reduce readmissions? And could the cost , but all involved agreed to try it. inhaled evaluate the patient’s understanding and proper improvements cover the cost of the FTE, making the change revenue‐neutral? This specific issue provided the pivot point for “People thought they were being more efficient by ‘multitasking,’” s use of the therapy. the patient’s best interest, for the respiratory therapists to take on quickly, the Kaizen event: Could we find enough time, “Actually, they realized they were providing poorer quality care and more personnel. If nothing changed, the team estimated that the some slowly. through work efficiencies, to halve the required time employees (FTEs). number of new FTEs—hiring one instead of Patient two—and t point for the Kaizen event: Could we find enough time, through allowing the respiratory therapists The Kaizen event focused on eliminating waste, to educate COPD patients, helping to reduce education red number of new FTEs—hiring one instead of two—and allowing so that respiratory therapists would have time to Kaizen work summary readmissions? And could the cost savings of the Batch educate patients, and support the goal of e COPD patients, helping to reduce readmissions? And could the cost was falling a time reducing COPD readmissions by 40% improvements cover the cost of the FTE, making poor the cost of the FTE, making the change revenue‐neutral? the change revenue-neutral? between
3
ummary
the cracks. “Confusion” is one of the eight wastes in health care, of which this is one example. Kaizen work summary
Lean efficiencies implemented during the event halved the expected number of required FTEs The Kaizen event focused on eliminating waste, from two to one. The efficiencies involved doing so that respiratory therapists would have time to educate patients, and support the goal of more work in real time, and standardizing equip- Respiratory therapists began treating and educating patients one by Batching—that is, educating several patients reducing COPD readmissions by 40% ment, supplies and processes among respiratory make sure each patient understood the instructions and was using e at a time—did not save time, and in fact, therapists. end, it actually saved time. resulted in poorer care. Seeing patients one
one of the eight wastes in health care, of which this is one example.
by one worked better and saved time. Real‐time charting. Related to the batching of treatment and educat notation. After a series of encounters, therapists would have to rely all. Mapping out their “future state” made the case for the efficiency computer on wheels. Now, therapists start and finish a treatment, ed the encounter before moving on.
Continuous flow and real‐time charting saved over two minutes per over a year, to one FTE.
Work assignments. Because work assignments were made at beginning of e therapists coming to work had to wait for their assignments. Now, assignmen preceding shift, and people can immediately start to work. The change saved respiratory therapist on each day and evening shift, or .3 FTE. “People thought they were being more efficient by Standardized carts. To eliminate searching for laptops, supplies, medications 4 . They also arran standardized and labeled each cart using the discipline of 5S ‘multitasking.’ Actually, they realized they were providing filled before the start of each shift. This change saved two poorer quality care and weren’t saving time at all.” minutes per person, per shift. (L, before; R, a “People thought they were being more efficient standardized Carts by ‘multitasking,’” said HPP’s Dwayne Keller. To eliminate searching for laptops, supplies,labeled. No
medications and labels, the team standardized and labeled each cart using the discipline of 5S. They also arranged for each cart to be (L, before; R, aft filled Respiratory therapists began treating and educat- before the start of each shift. This change saved standardized an ing patients one by one, staying at the bedside to two minutes per person, per shift. make sure each patient understood the instructions and was using each therapy properly. In the end, it actually saved time.
“Actually, they realized they were providing poorer quality care and weren’t saving time at all.”
real-time CHarting
Related to the batching of treatment and education was the batching of chart notation. After a series of encounters, therapists would have to rely on their memory to chart them all. Mapping out their “future state” made the case for the efficiency that could be achieved with a computer on wheels. Now, therapists start and finish a treatment, educate the patient, and chart the encounter before moving on.
Continuous flow and real-time charting saved over two minutes per treatment, which translated, over a year, to one FTE.
4
Sort, set in order, shine, standardize, and sustain. and sustain) require leader input to ensure their co
A computer on wheels made one-by-one treatment and education more efficient and accurate.
A computer on wheels made onebyone
treatment and education more efficient and (Top, before; bottom, after) Each drawer in each accurate. cart was standardized and labeled. Anyone can easily find (or stock) items in the cart now.
Having all items in a predictable place, always at the ready, means less confusion for workers and more safety for patients. However, the team 4 Sort, set in order, shine, standardize, and sustain. These are the elements of order. The Work assignments. Because work assignments were made at beginning of each shift, respiratory discovered and corrected an even more critical therapists coming to work had to wait for their assignments. Now, assignments are made on the worK assignments and sustain) require leader input to ensure their continuation. preceding shift, and people can immediately start to work. The change saved 10 minutes per Because work assignments were made at begin- patient safety problem in one drawer. The drug respiratory therapist on each day and evening shift, or .3 FTE. ning of each shift, respiratory therapists coming Xopenex, used to treat wheezing, was found in Standardized carts. To eliminate searching for laptops, supplies, medications and labels, the team containers that contain two dosages: to work had to wait for their assignments. Now, identical 4 . They also arranged for each cart to be standardized and labeled each cart using the discipline of 5S .63 mg and 1.25 mg. assignments are made on the preceding shift, filled before the start of each shift. This change saved two and people can immediately start to work. The Manufacturers minutes per person, per shift. (L, before; R, after) Carts are standardized and are not required to provide labeled. No more opening drawers to search. change saved 10 minutes per respiratory therapist
on each day and evening shift, or .3 FTE.
radically different labels for differing dosages, making it all too easy for a clinician to grab the wrong dose. (L, before; R, after) Each drawer in each cart was Until drug manufacturing rules change, standardized and labeled. Anyone can easily find (or stock) items in the cart now.
Manufacturers are not required to provide radically all too easy for a clinician to grab the wrong dose5. U must make accommodation through human factors placement of lookalikes to call out and avoid this pot To address the Xopenex issue, the team moved the d distinctive labels to call special attention to the dosages. hospitals must make accommodation through human factors engineering, using graphic labels and distinctive placement of look-alikes to call out and avoid this potentially deadly confusion. To address the Xopenex issue, the team moved the different doses to different drawers with highly distinctive labels to call special attention to the dosages. sustaining
The last of the 5S’s is “sustain,” and it’s usually the most difficult to achieve. Without commitment from everyone on the team, and support from leadership, things have a way of drifting to a less ideal state. However, at UPMC St. Margaret, an impromptu check after one year revealed that the respiratory therapy carts remain standardized, clean and reliably stocked. Additional improvements have been made. The commitment remains high.
The team discovered and corrected a potential patient safety issue, when Sustaining. The last of the 5S’s is “sustain,” and it’s u different doses of the same drug, in identical commitment from everyone on the team, and suppo containers, were discovered side-by-side. to a less ideal state. However, at UPMC St. Margaret that the respiratory therapy carts remain standardiz improvements have been made. The commitment re
Results In one year, 2008-2009, UPMC St. Margaret posted a 48% reduction in readmissions for COPD, exceeding its aggressive goal of 40%. In human terms, 16 fewer people required readmission, at an estimated savings to the hospital of over $85,000.
added staff member helped to improve the quality of patient encounters with respiratory therapists.
While the Kaizen lasted just three days, the improvements were immediate, and have been sustained. Employees have begun spreading Lean Results Significantly, the Lean improvements saved the thinking throughout the organization, and Lean equivalent of 1.3 FTEs, enabling the hospital In one year, 2008‐2009, UPMC St. Margaret posted a 48% to is becoming part of day-to-day work at UPMC St. Margaret. add just one FTE, not the predicted two. The exceeding its aggressive goal of 40%. In human terms, 16
estimated savings to the hospital of over $85,000. imPaC t of CoPd readmission reduC tion ProjeC t at uPmC st. margare t
janjanreadmissions
30-day readmission rates % of Discharges with Primary COPD Diagnosis, Readmitted within 30 Days for COPD or Pneumonia
5 may
may Prevented savings @ Actor Dennis Quaid has a lawsuit pending over easily confuse 2008 2009 Change (5 mos.) $5,400/admit the massive overdosing and near death of their newborn twin http://news.injuryboard.com/dennis‐quaid‐files‐lawsuit‐over‐
12.4%
6.4% (48.2%)
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