Process Improvement Project
- 1. Chemotherapeutic Agent Process Improvement ProjectVeteran’s Affairs Ann Arbor HospitalCollege of Engineering, University of MichiganProblem Solving EngineeringMolly Beggs, Austin Kloske, Brittany Morales,Kyle Valentine, C. Paoro Yin-Blair1
- 3. I. Project Definition3
- 4. Project BackgroundTeam: Problem Solving Engineering (PSE)Client: Veteran’s Affairs (VA) Ann Arbor Healthcare System, Chemotherapy Outpatient ClinicProject Name: Chemotherapeutic Agent Process Improvement ProjectThree primary areas involved: the Chemotherapy Outpatient Clinic, the Pharmacy, and the Technician Lab4
- 5. Project DefinitionProblem: chemotherapy patients experience long wait times, sometimes up to 8 hoursProject goal: minimize patient wait time in chemotherapy outpatient clinicPatient wait time: duration of time from when patient arrives to outpatient clinic to time drug is administeredPSE goal: reduce wait time to 30 minutes or less for 80% of patients5
- 7. II. Summary of Activity and Methods7
- 8. Summary of ActivityData Collection:Conducted expert interviews with 5 nurses, 4 pharmacists, and 3 techniciansCollected historical data (arrival times and cancellation rates)Gathered relevant chemotherapeutic agent details (i.e. cost, shelf life)Conducted 65 hours of time studies of the processBenchmarked with the University of Michigan HospitalData AnalysisDetermined current stateMicrosoft Excel and Minitab 15 Statistical Software to analyze dataUtilized Lean Principles:Process Mapping to identify the current state of the processCause and Effect Diagrams to identify problem areas for improvementPareto Analysis to detect areas with the greatest opportunity for improvementDetermined feasibility of recommendations and implementation methods8
- 9. III. Summary ofData and Analysis9
- 10. Current State AnalysisSummary of Total Patient Wait Time10
- 11. Current State AnalysisHistorical Data of Patient Arrivals11
- 12. Current State AnalysisProcessing Time for Individual Steps12
- 13. Benchmarking withUniversity of Michigan Cancer CenterMet with Cancer Center Pharmacist at University of Michigan Hospital30 Minute incremental scheduling blocksChair SchedulingLight signaling systemStandardized treatment formsElectronic Tracking System13
- 15. Criteria for RecommendationsReduction of primary quality metric (Total Patient Wait Time)Benchmarking of similar processesConsider employee interest and inputTransferability of recommendations to a new locationPotential solutions will not add or subtract major resources (facilities, equipment, labor) and have little to no costRecommendations were ultimately divided into three areas: Chemotherapy Outpatient Clinic, Pharmacy, and Technician Lab15
- 16. A. Chemotherapy Outpatient ClinicStandardized Scheduling ProcedureChair SchedulingImportance of Scheduling DocumentRemoval of Clinic’s side of Pass-Way Door16
- 17. Recommendation A1: Standardized Scheduling ProcedureDescription: A standard procedure for RN’s to schedule patientsBenefit: Allow RN’s to have an appropriate number of patients per block of time and thus giving patients adequate attention, reduces overall wait time for patients, and helps pharmacy prepare agents Support: Patients often arrive in batches which cause bottlenecks and increase wait timeImplementation: Distribute the Standardized Scheduling Procedure work document to all RN’s, education of new procedureCost: Time spent on education (~ 1 hour)17
- 18. Recommendation A2:Chair SchedulingDescription: Scheduling patients per chair in the clinicSupport: Scatter plot of patient arrival time Benefit: Reduce wait time for chairs, proper allocation of patients per RN, allow for appropriate attention to patientsImplementation: Education of procedure to RNsCost: time spent on education and scheduling18
- 19. Recommendation A3: Importance of Scheduling DocumentDescription: A paper document for patients that explains why they need to arrive on time to appointmentsSupport: Patients do not follow scheduling policies without strict enforcementBenefit: Aids the scheduling procedure, because for scheduling to be effective, patients must arrive on timeImplementation: Point nurse will include this document in patients initial briefing session and go over it with each patientCost: Time spent explaining to patients (~ 5 minutes)19
- 20. Recommendation A4: Removal of 1 Side of Pass-Way DoorDescription: Complete removal of door on clinic’s side of pass-throughSupport: Large variance in delivery time from dumbwaiter to pass-way door and large variance in time from pass-way door to administration of agentBenefit: Reduce wait time for patientsImplementation: Facility maintenance will remove the doorCost: Facility maintenance20
- 21. B. PharmacyStandardized Chemotherapy Order FormsStandardized Work PolicyPrepare Chemotherapy in AdvanceAccess to CPRS TemplatesSignal Lights21
- 22. Recommendation B1: Standardized Chemotherapy Order FormsDescription: Create and implement a set of standardized order formsForms will be unique to each treatmentEasier to fill out patient and dosage informationSupport: Per pharmacists’ request and UM BenchmarkingBenefit: PSE can reasonably estimate an improvement of 5 minutes per order formImplementation: Pharmacists have begun work on new templates, once complete (2-3 weeks) begin useCost: No cost22
- 23. Recommendation B2: Standardized Work PolicyDescription: Patient files should be completed the evening before the patient is to be seenCurrently happens a majority of the time; should be enforcedEspecially important for Monday’s filesSupport: The step for pharmacists to complete paperwork has a larger variation when the forms are not completed beforehandBenefits: Uncompleted files take average of 12 minutes to complete the paperworkAt least 10 minutes can be removed from patient wait timeSaves more time if doctor consent is missingImplementation: Create a policy that pharmacists must complete files the day before patients are expected (immediate implementation)Cost: No Cost23
- 24. Recommendation B3: Prepare Chemotherapy in AdvanceDescription: Prepare certain chemotherapeutic agents in advance Support: The total time in the Technician Lab can be removed from the patient’s wait timeBenefits: Can decrease patient wait time by 20-30 minutesImplementation: Determine if any chemotherapeutic agents should be made ahead and treat them as preorders (can be implemented as soon as agents are chosen)Cost: Expected costs of common chemotherapeutic agentsAssumed 15% cancellation rateEstimated average cost per dose of each chemotherapeutic agent24
- 25. Recommendation B4: Access to CPRS Templates Description: Pharmacists/Computer Technicians need access to the CPRS templatesSome prescription templates are unclearOnly doctors have access to change templatesSupport: Many instances of confusion between doctors and pharmacists cost up to 30 minutesBenefits: Can save about a half hour of clarification timeImplementation: Grant access to CPRS templates (immediate implementation)Cost: None25
- 26. Recommendation B5: Signal LightsDescription: Place a signal light in the Outpatient Pharmacy with two light switchesSupport: If phones are busy the Outpatient Pharmacy is not calledBenefits: Can reduce an average of 5 minutes for the chemotherapeutic agent to reach the Outpatient ClinicImplementation: Install a light in the outpatient pharmacy and indicator light switches next to the dumbwaiter on both floorsCost: $19.70 for two switches26
- 27. C. Technician LabTubing and Draining IV Bags in AdvanceSignal LightsPosted PoliciesStandard Work InstructionsFolder RacksWhite Board27
- 28. Recommendation C1: Tubing & Draining IV Bags in AdvanceDescription: Attach tubing and remove extra solution so IV bag is ready for CA at time of patient arrivalSupport: Median processing time of 6 minutesBenefit: Shorter lead time, free IV technicianImplementation: Write standard work instruction, pharmacists share folders with technicians prior to patient arrival (Next 2-4 weeks)Cost: (0.15)*($4.90)*($0.62) = $0.50 / CA = (Cancelation Rate)*(Tubing Cost)*(Bag Cost)28Drain appropriate amount of fluid.Mark bag and hang in queue.Attach tubing to IV bagSelect correct tubing and close drip chamber
- 29. Recommendation C2:Signal LightsDescription: Replace pharmacy intercom system with ‘Drug Ready’ signal lightsSupport: CA’s commonly wait up to 15 minutes to be checkedBenefit: Reduce chances for Pharmacists to forget announcement or not hear announcementImplementation: Install two new light fixtures above pharmacy desk, install two new light switches in Technician LabCost: $28.11 + electrician time29
- 30. Recommendation C3: Posted PoliciesDescription: Summarize and post all work policies relating to technician labSupport: Certain policies are currently passed between techs as hearsay (i.e. CA’s that must be produced in chemo hood)Benefit: Less time loss over discussion, Eliminate time loss due to CA’s taking space in chemo queueImplementation: Organize, Outline, Write, Post (Next 2-6 weeks)Cost: Lead Technician Time30
- 31. Recommendation C4:Standard Work InstructionsDescription: Clear descriptions of common tasks (not to replace 797 logs)Support: Current lack of standardized trainingBenefit: Increase confidence between techniciansImplementation: Photograph, write, print, post, review, update, repeat (Next 1-6 weeks)Cost: Lead Technician Time31
- 32. Recommendation C5:Wall-Mounted Folder RackDescription: Rack to hold chemo folders in queueSupport: Congestion related to larger queuesBenefit: More counter space, reduce mixing queue order Implementation: Order, Hang (Next 2 weeks)Cost: $28.6832Pre-makesPreps
- 33. Recommendation C6:White BoardDescription: Wall mounted whiteboard in main IV room (36”x24”)Support: Techs often do not transition between shiftsBenefit: Less information would be lost across shiftsImplementation: Order and hang white board (Next 2 weeks)Cost: $43.5933
- 34. V. New Process and Future State34
- 35. Future State of Process35Prior to Patient ArrivalPost Patient Arrival
- 36. Future StateExpected Patient Wait Time Reduction36Expected distributionRecommendations will reduce expected maximum wait time from 89 minutes to 30 minutes for 80% of patients.Current distribution
- 38. Tracking Systems in Lean Healthcare Systems38Continual improvement methods are now a part of Healthcare Systems
- 39. Implement an electronic tracking system similar to the system used by UMHS in the near future
- 40. All departments would be kept up to date on patient and medication information relative to their appointment times
- 41. Gauge improvements and identify wastes39Thank You!Questions?
Editor's Notes
- #14: The University of Michigan healthcare system (UMHS) was selected for the purposes of this project because it is widely accepted as one of the best-in-class healthcare systems in the country. US News and World Report has named UMHS to the "Honor Roll of America's Best Hospitals” for 14 straight years.This meeting re-enforced many of the recommendations we planned to make to the VA Hospital
- #18: Molly: Make sure you refer to slide 11 for scatterplot graph
- #20: Molly: Five minutes is NOT part of patient wait time, but time point nurse must spend
- #21: Molly:Through observations, nurses do not hear when agent was passed throughHelp RN’s prioritize tasks in the most effective manner
- #39: PSE feels it is vital the VA hospital’s continued success to adopt an electronic tracking system similar to the system used by UMHS. Continual improvement methods such as lean and six sigma are no longer monopolized by the manufacturing industry. If fact Toyotas approach to reducing any waste in the process is widely being used in Healthcare systems across the Country.An Electronic Tracking system would keep all departments in the loop and up to date on any patient, medication or schedule changes. It would also serve as a to gauge the Hospitals improvements and find locate opportunities for improvement.NO WAY TO TRACK OUR IMPROVEMENTS WITHOUT TRACKING
- #40: Austin: We hope this project will serve the maiden voyage for future relationships between the VA and UM IOE