1 Improvement of efficiency at the short stay department in a university hospital
dr. E.A. te Velde
Oncology surgeon at the VUmc University Medical Center Amsterdam Supervisor Prof dr R. J.M.M. Does
MBA thesis Amsterdam Business School of the University of Amsterdam, The Netherlands
Address for correspondence: Dr. E.A. te Velde. MD, PhD VUmc Amsterdam
Department of surgical oncology 7F21 PO Box 7057
1007 MB Amsterdam The Netherlands
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Table of contents page
Abstract 3
Introduction 4
Mandatory change
Safety and zero defects: an obligation to our patients 5
Lean six Sigma 7
Continuously process improvement 8
DMAIC for improvement of a process 11
DMAIC in short stay 14
Define Measure Analyze Improve Control Discussion
Short stay in a high complex environment Leveling out the workload and improve planning Quality improvement and cost reduction
Change as a result of a strategy
Conclusion References
3 Abstract
Improvement in healthcare is mandatory to meet the obligation to our patients. In order to change, healthcare needs to learn from organizations, which apply continuous improvement
to obtain zero defects. Only then the care for the patient can be optimized. Here a project approach to improvement is undertaken by using the DMAIC lean six sigma
methology: In a university hospital one aspect of the complicated healthcare industry is studied. This is a study on the journey of the short stay patient. We found that the bed occupation on the short stay ward in a university hospital can be increased by 73%. Here, the lean six sigma DMAIC approach was very applicable and effective in streamlining and leveling out the short stay process. Although, ideally, the choice for a project should be made strategically, we hereby aim to improve the strategy by showing that this project can change the quality of care for our patients. By improving logistics of the short stay patients and thereby saving money, the workflow of the caretakers is improved. More time will then be available for the caretakers to spend on being part of a learning organization.
4 Introduction
One of my co-workers recently asked: when are we finally going to stop improving? The World we live in is constantly changing. Disruptive developments as the development of the internet and microchips facilitate our communication and change our way of life. In order to deal with this external reality in which everything is constantly evolving or emerging organizations need to be even more flexible and responsive than before. Organizations can survive this changing environment by learning and growing (Kenny, 2006). Also in the healthcare-business, learning is needed to survive. Learning and growing implicate change. Mandatory change
Change adaptability is an important property of a sustainable organization. As Johnson said about a learning organization: “Change is the only constant we should expect in the
workplace” (K.W. Johnson, 1993). However, some employees have a natural human reluctant reaction to change. Change for employees can mean they have done something wrong all along. Especially in a working environment of healthcare, were professional healthcare takers have years and years of scholarship and training, experience and
knowledge, and respect for their individual capabilities is part of their existence, change can be disapproved. Indeed, without learning, organizations and employees repeat old practices (Garvin, 1993) .
An organizations’ performance is shown to be improved by organizational learning (Lopez, 2005; Kululanga, 2001). Organizational learning is said to be important for organizations to survive (Scott-Ladd, 2004) not just because change is needed, but also because through organizational learning organizations develop core competencies in order to gain
competitive advantage over other organizations (Pemberton, 2001). This means that what discriminates your organization from others (i.e., that what makes your organization stand out and determines its value) is dependent on learning as well. In other words,
organizational learning is said to be the key element of any effort to effectively implement sustainable development in organization (Siebenhuner, 2007).
How does one become a learning organization? A learning company was defined as an organization that facilitates the learning of all its members and continuously transforms
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itself (Pedler, 1997). This seems particularly applicable to an academic environment as an university hospital like ours. There seems however to be a substantial difference between individuals learning at a university and a so called learning organization. The learning organization is ultimately about learning relationships and about what goes on between people and not just think of learning as a property of the person. As Senge said: “How can a team of committed managers with individual IQs above 120 have a collective IQ of 63?“ (Senge, 1990). In a hospital setting where teamwork and multidisciplinary work is more and more standard of care the organization should be more than just the add on of individual caretakers. Teamwork, communication, training, the worker to be part of a learning organization are mandatory. However, there must be time for reflection and analysis, for development and adjustment of strategic plans, development and improvement of clinical pathways, agreement upon what parameters are important for determining quality of care and acting upon feedback of patients. All these aforementioned actions are time consuming, and learning is found to be difficult when employees are hussrried or rushed (Garvin. 1993), as is often the case in healthcare workers. Scheduling time for learning and reflection is therefore needed to become a true learning organization.
Safety and zero defects: an obligation to our patients
In aviation’s Crew Resource Management (CRM) this abovementioned knowledge about dedicated time for learning is translated to action. In aviation, the role of the community’s call for aviation workers to work as safe as possible and commit to learning and improving communication as a team is obvious (Helmreich, 2000). Fortunately, in analogy to the aviation industry also for healthcare workers CRM has been developed and promoted (Institutes of Medicine. 2000; Musson, 2004). This CRM is specifically designed to reduce errors and make the working environment more safe. In concordance, organizational learning was first defined as the detection and correction of error (Argyris, 1978).
Detection of error and the concept of safety in healthcare is the basis of the wellbeing of our patients. In order to reduce the errors in healthcare, five years ago the Dutch safety
management program (VMS) for hospitals was initiated by the Netherlands institute for health services research (Nivel). By the use of eleven thematic approaches the processes in healthcare are described and well defined outcome measures given. Currently, the
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potentially preventive errors have been reduced by 45% and the potentially preventive deaths has been reduced by 53%. This means that the absolute number of patients that have died as a result of medical of logistic errors has come down from 1960 in 2008 to 970 in 2011/2012 (https://www.nivel.nl/nieuws/nederlandse-ziekenhuizen-zijn-veiliger-geworden). Despite all efforts, human errors are common. Errors lead to incidents and calamities. To learn from these incidents and calamities the Prevention and Recovery Information system for Monitoring and Analysis (PRISMA) was developed. The PRISMA focusses on detailed description of the incidents by structured interviews with the involved care takers, and thereafter root cause analysis according to a described classification, so that the cause of the errors is known and actions can be undertaken in order to prevent the errors in the future. (Hemmes, 2008; Snijders, 2009). Why did the Herald of Free Enterprise sink? It was not because someone, a specific worker, left the bow door open and did not push the button, but because the system was not designed so that the bow was being closed. It was a combination of multi-factorial reasons that this disaster happened.
Figure 1. from Carthey, 2013. Understanding safety in healthcare: the system evolution, erosion and enhancement model. Journal of Public Health Research 2013; volume 2:25. The multifactorial managerial causes of an error, leading to an incident.
Understanding human factors in errors in healthcare is depicted in the Swiss cheese model of Reason (Reason ,1990) (see Figure 1.). This schematic drawing clearly shows that one single error becomes an incident only if it is multifactorial.
The concept of Zero defects was first developed in the Ministry of Defense of the USA and later in the aerospace industry as a result of desire to reduce cost by re-work of missile manufacturing (Harwood, 1993). Zero defects conceptually aims for reduction of defects
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through prevention by motivating people to prevent mistakes by developing a constant, conscious desire to do their job right the first time (Halpin, 1966). In the organizations of the healthcare business the employees have an obligation towards their patients to work as safe as possible. Although the former statement is widely accepted, the concept of zero defects is not always adapted by all managers. Instinctively, as we have stated above, it is hard to believe that we can eliminate (human) errors completely. On the other hand, if we do not strive to absolute nil, we will not even come close.
Lean six Sigma
Later on, the concept of zero defects became important aspects of the Six Sigma and Lean thinking. Motorola firmly believed that by reducing variations in a process, fewer defects would be produced. This methodology, called Six Sigma, has been widely implemented in companies such as General Electric, Allied Signal and many others, with tremendous success in terms of customer satisfaction and global profitability (Gras, 2007). Anything that could lead to customer dissatisfaction is named a defect in the Six Sigma addition to the lean thinking. And as “Customers are scarce; without them, the company ceases to exist” (Kotler, 1997) the survival of the organization is dependent on customer satisfaction. This also holds true for healthcare. Patient satisfaction is based on their perceived sense of safety. Patient satisfaction can be enhanced by reducing errors to a minimum. Six Sigma is developed on the basis of the defect frequency that could be cut by 1000-fold if the variation was held at 1/6 of the difference between the process mean and the control limits (Hinckley, 2006; Westgard, 2006). Hence, there is an exponential correlation between the value of the σ level and the number of defects. The six sigma objective symbolizes the systematical pursuit of reducing errors to a minimum (see Figure 2.). Six Sigma aims to reduce output variation and thus errors/defects by using statistical analysis as well as root cause analysis.
Figure 2. Depiction of the development of the Six Sigma. The six sigma objective symbolizes the systematical pursuit of reducing errors to a minimum.
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Defects were defined as any form of rework or anything that is thrown out. Lean thinking is characterized by the collection of best practices by Toyota and other Japanese companies. Lean thinking is actually the accumulation of recently published quality improvement principles. It combines all principles in a structured and integrated approach. It focusses on processes in respect to quality, speed, flexibility and low costs (Roos, 1991). In a classic manuscript Toyota's lean production system is described as the International Motor Vehicle Program (IMVP). IMPV is a five-year, five-million dollar research project directed at
identifying production factors leading to success in the global automobile manufacturing industry. IMVP aimed to synthesize the success factors, document their effect on organizational operations, and to develop a more efficient production strategy.
Later lean thinking and Six Sigma was adapted by numerous industries, including healthcare. In: An Industry Approach Transforms Healthcare: A 7 Year Journey, it is described how an university hospital in the Netherlands successfully implemented lean six sigma management in healthcare. This hospital has set a standard; they have won the excellence in practice gold award in 2014 from the European Foundation of Management Development. The hospital needed to change, since they were facing a growing demand of an aging population, with diminishing numbers of nurses, rises in medical materials and vast financial cuts from the Dutch government. In the Virginia Mason Institute in Seattle USA the lean thinking has resulted in a hospital specific lean system, by adopting the lean thinking of Toyota, called the Virginia Mason Production System (VMPS). Their mission is to improve the health and wellbeing of the patients. Therefore, also in their statement mission improving is a very important aspect.
Continuously process improvement
A process is defined as a series of steps or actions that delivers a service or product that adds value to the costumer, i.e. in healthcare: the patient. Healthcare is a complex system of interlinked processes. Therefore, improvement in healthcare can be managed as any other processes. How is improvement of a process in healthcare achieved?
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The lean thinking system embraces the concept of improvement in a continuous manner. Continuous improvement is defined as the ongoing improvement of products, services or processes through incremental and breakthrough improvements (http://asq.org/learn-about-quality/continuous-improvement/overview/overview.html). It is important to use the word continuous, since the word "continual" means continue in discrete jumps. And as we have said before, continuous improvement requires a commitment to learning (Garvin., 1993) and as such a learning organization. To continuously improve processes Lean Six Sigma provides data-driven techniques.
A widely used and commonly known tool for continuous improvement of processes is a four-step quality model—the plan-do-study-act (PDSA) cycle, also known as the Deming or Shewhart wheel or cycle. It originated in the 1920s with Walter A. Shewhart. The PDSA Cycle is a systematic series of steps for gaining valuable learning and knowledge for the continual improvement of a product or process. Deming reintroduced the Shewhart cycle in 1986 (Deming, 1986). He focused on an upper management philosophy for quality improvement, and not so much on the employees on the floor. Deming explained as follows: The cycle begins with the Plan step. This involves identifying a goal or purpose, formulating a theory, defining success metrics and putting a plan into action. These activities are followed by the Do step, in which the components of the plan are implemented, such as making a product. It is important to also include training and education in this step, and make sure all workers know what the agreement is on. Next comes the Study step, where outcomes are monitored to test the validity of the plan for signs of progress and success, or problems and areas for improvement. The Act step closes the cycle, integrating the learning generated by the entire process, which can be used to adjust the goal, change methods or even reformulate a theory altogether. The act step is often mistakenly seen as the Do step. The act step however is reactive to the previous actions taken. These four steps are repeated over and over as part of a never-ending cycle of continual improvement. Note that this author uses the word
continual, in an error where Lean Six Sigma has not yet evolved to what is is now. The PDSA cycle emphasized the prevention of error recurrence by establishing standards and the ongoing modification of those standards.
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Another management theory for improvement was porposed by Juran (Juran, 1986). He introduced quality management via his famous trilogy: planning, control and improvement (see Figure 3).
Figure 3. The Juran’s Quality trilogy describes three management processes for quality improvement. Quality from the costumers’ perspective by Juran was described as“fitness for use.” This definition implies that more is not necessarily better. Instead, the patients’ needs and expectations should be the focus. Juran’s “fitness for use” definition has two subsidiary definitions of quality as “features” and “freedom from deficiencies: 1. Higher quality means a greater number of features that meet customers' needs and 2. "Freedom from deficiencies" means that higher quality consists of fewer defects. Hereby, the concept of quality is closely linked to the zero defects concept.
How does one addresses a process in healthcare? Deming said: “In God we trust…and all others must bring data.” There are many data from various systems, such as administrative, research, clinical, human resources, etc., so where to begin to identify which areas to focus on in quality improvement efforts? Pareto’s rule shows that addressing 20% of those processes will get us 80% of the impact (Pareto, 1971). Identification of the vital few becomes feasible. So, addressing one process at the time can improve healthcare. Even more than with the PDSA tool, continuous improvement as the lean thinking has introduced the management of the improvements comes from involvement of employees. The improvements are specifically managed bottom-up with top down control (see Figure 4.). Ideally, employees are asked to contribute daily (continuously) to improvement by posing suggestions to alter their daily work. This can vary from trash-bin replacement closer
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to the worksite of the employee to project initiatives. By ensuring that the initiative is managed as a strategic project, there are increased opportunities for success.
Figure 4. The organization of process improvement can be top-down or bottum-up. The lean Six Sigma in-between approach is project-driven and executed bottum-up with top-down control.
DMAIC for improvement of a process
Originally described as a method for variation reduction, The DMAIC Six Sigma approach of Define, Measure, Analyze, Improve/Implement and Control (DMAIC) is a routine for changing established routines or for designing new routines (De Mast, 2012; Schroeder, 2008). DMAIC is an acronym of the five interconnected project phases (define, measure, analyze, improve, and control) that provide a structured approach to process quality improvement (Organization-wide approaches: Six Sigma—the DMAIC methodology. American Society for Quality Web site. http://www.asq.org/learn-about-quality/six-sigma/overview/dmaic.html.Peterka P. The DMAIC method in Six Sigma. Buzzle.com Web site. http://www.buzzle.com/editorials/10-24-2005-79640.asp. Published October 25, 2005). DMAIC aims to improve processes by careful diagnosis through measuring and assembling information (Koning, 2006; van den Heuvel, 2005; Mast, 2012). First introduced by the telecommunication company Motorola in 1987, engineers had discovered that higher quality in industrial processes lead to lower manufacturing costs (Harry, 2000). Efficiency and reliability of the care given by the hospital staff mostly determine quality of care and patient satisfaction. Inefficiencies can be associated with administrative, logistical, and operational aspects and should be eliminated. This can be achieved by measuring the inefficiencies and based on the diagnosis, changes can be suggested for process improvement to improve quality.
The value of using DMAIC, whereby a standard process is monitored to define the problem, the work-flow process is measured, results are analyzed, and improvements are made,
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followed by control of the gains, is found to be “paramount to success” for improvements (Aakre, 2010). Indeed, since the introduction of the DMAIC, many studies have proven its usefulness in quality and safety improvement to achieve patient satisfaction. For example, studies on the management of patients undergoing prosthetic hip replacement surgery (Improta, 2015), on central line-associated infections in an ICU unit (Loftus, 2015), on vena cava filter retrieval rates (Sutphin, 2015), on reducing liver transplant length of stay (Toledo, 2013), on diagnostic imaging processes (Taner, 2012), on ergonomics in a dental clinic (Bedi, 2015) all have shown that the Six Sigma DMAIC can help to improve healthcare.
Comparing different quality management initiatives in one hospital, i.e. the Balanced Scorecard, Six Sigma and Team Training showed that Six Sigma facilitates focused improvement within operations (Meliones, 2008). It is therefore important to determine which improvement initiative is most appropriate in a given situation, as shown in Figure 5.
Figure 5. The aid to choose the execution of a project is depicted here. Lean Six Sigma is appropriate in an high complexity environment with an unknown solution to the problem.
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The short stay patient
A short stay unit is a Monday-Friday ward that provides specialized care for patients requiring hospitalization less than 5 days and who are dischargeable as soon as clinical conditions are resolved. In VUmc the care for the short stay patients is protocolled and highly standardized. Literature on this form of short stay care dates from 70’s (Laskin, 1972; Cerce, 1981). An effect meta-analysis evaluating the effectiveness of short stay in terms of length of stay, mortality and readmission rates showed a reduced length of stay with comparable mortality and readmission rates (Damiani, 2011). It was also concluded that the reduced use of hospital beds and optimization of the turnover rate of hospital staff could minimize economic losses, and reduce hospital costs and waste of personnel time. In the current situation (first half year of 2015) the utilization of the bed occupation of the Short Stay unit of the university hospital is not optimal. The nurses experience peak hours, resulting in refusing patients admittance and consequently empty beds at different hours. These empty beds can be seen as inefficiencies, i.e. defects in the process. Since this process is situated in a high complexity environment and the solution to the described problem is unknown, the process improvement methodology DMAIC of Lean Six Sigma was chosen here to solve the problem.
The objective of our study is to improve the admittance logistics to level-out the workload of care of the short stay patients in our university hospital by using DMAIC. Hereby, the quality of care should be optimized, whereby optimal utilization of the hospital beds will eventually reduce costs.
14 DMAIC in short stay
A. Define phase
A DMAIC project starts with a clear definition of the process. In our current study, the process is the improvement of the short stay unit. The problem is defined by the bed occupation rates that were low and the uneven workflow for the nursing staff. During rush hours, they are understaffed, whilst other hours during the day the staff is not having enough patients to take care off. Financial benefits of this project are realized by better utilization of the beds in the wards and the staff aside those beds. By using Lean Six Sigma’s DMAIC methodology, the project started with a project charter, which is important in project management principles. The project charter determines the project leader, process owners, scope, financial benefits, timelines and auxiliary members of the project team. A SIPOC (Supplier, Input, Process, Output, Customer) was made, leading to a detailed flowchart of the process at micro level, to put the problem in perspective. Furthermore, the process leader performed a stakeholder analysis, to chart the stakes and the influence of the people involved.
The strategic focal points of this study are to level the work load staffed to volume and increase the revenue from the perspective of the hospital by using more available beds.
B. Measure
The next step is to link the project objective to specific and quantifiable process measures, the so-called critical-to-quality measures, or CTQs (Figure 6.). The CTQ flowdown aims to depict the rationale underlying this project and shows the translation of the defined CTQs in relation to an organization’s performance indicators and strategic focal points of the organization (de Koning, 2007).
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Figure 6. CTQ flowdown of the study relates CTQ’s to the organization’s performance.
The CTQs including their operational definitions are also depicted in Table I. The operational definition of a CTQ consists of three elements. Firstly, it is specified per which entity the CTQ is measured. This entity is called the (experimental) unit. Secondly, the measurement procedure for the CTQs is specified. Thirdly, the goal for the CTQs is stated (e.g. as low or high as possible). Next, a validation of the measurement system is required to ensure the quality of the collected data (in terms of precision, accuracy, resolution), and thus the quality of the input for decisions to be made later on in the project.
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According to the measurement plan a retrospective data collection was performed from January 1st 2015 until June 1st 2015 form the digital hospital information system (ZIS). This data included patient characteristics, admission and discharge information as well as staff schedules.
The reality is that very often data quality is expected to be higher than it usually is and that analysis of the data shows the need to improve data capture (Merkley, posted in Quality and Process Improvement). Therefore verification and validation of the data, especially when retrospectively retrieved from our hospital systems, is mandatory. This is a standard part of the DMAIC process. This data was validated by a comparison with the paper files of a random sample of 20 patients as well as staff schedules.
C. Analyze
From the data based diagnosis of the current process performance of the short stay ward we will conclude on the basis of the CTQ’s what the current performance is. Based on this data we will generate ideas to improve the performance of this ward. We will finalize this section by a preferential choice of improvement strategy and will indicate how these improvements should be implemented and how the performance can be monitored.
CTQ # patients on the short stay ward. From January 2015 until June 2015 910 patients were admitted to the short stay ward.
Figure 7. the CTQ bed occupation on the short stay ward. 1st Quartile 7,000 Median 10,000 3rd Quartile 13,000 Maximum 26,000 10,298 10,699 10,000 11,000 4,157 4,440 A-Squared 5,44 P-Value <0,005 Mean 10,499 StDev 4,294 Variance 18,438 Skewness 0,239101 Kurtosis 0,159982 N 1771 Minimum 0,000 Anderson-Darling Normality Test
95% Confidence Interval for Mean 95% Confidence Interval for Median 95% Confidence Interval for StDev
24 20 16 12 8 4 0 Median Mean 11,0 10,8 10,6 10,4 10,2 10,0 95% Confidence Intervals
Summary Report for Aantal bezette bedden
25 20 15 10 5 0 100 80 60 40 20 0 Mean 10,50 StDev 4,294 N 1771
Aantal bezette bedden
P er ce n t 17 ,5 6 95 20 ,4 9 99 Empirical CDF of Aantal bezette bedden
Normal
Opmerking [E.A.1]: Deze komt van Rob. Zou hij kunnen helpen?
Opmerking [DR2]: Aan de layout van de plaatjes mag nog wel wat gedaan worden. Nu wisselen Engels en Nederlands elkaar af.
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As depicted in figure 7, the CTQ bed occupation was 10,5 beds (+/- 4,3 beds). The beds were more than 90% occupied during 154 hours of the 1771 hours measured period. Off the 34 available beds, 26 was the maximum occupied number, in week 26. Less than 21 beds were occupied for 99% of the time, and less than 18 beds for 95%. Week 4 was the most occupied week, with 63 patients.
The CTQ # admissions and discharges is depicted in Figure 8. This is practically translated as the turnover work for the nurses per day. It is shown that there is a large variation during the day; resulting in peak hours. The amount of workload in the peak hours determines the flexibility of the workers and capability of the ward to accept more patients.
Figure 8a. the number of admissions per hour per day per nurse. On the Y-axis the number of nurses present per hour are given. On the X-axis the hours of the day are given. The different colors represent the different days of the week (Mon-Fri).
Figure 8b. the number of discharges per hour per day per nurse. On the Y-axis the number of nurses present per hour are given. On the X-axis the hours of the day are given. The different colors represent the different days of the week (Mon-Fri).
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The CTQ the number of transferred patients per day from the short stay ward is summarized in Table II. We expected that due to the closing in the weekend the majority of patients are being transferred to other normal care (no high care) wards on Friday. Indeed, 20% of the patients are transferred from the short stay on a Friday, as opposed to 2% on Wednesday and 0-1% on Mondays, Tuesdays and Thursdays.
Tranfers Day N Mean SE
Tue 175 0,98857 0,00806
Thur 192 0,98958 0,00735
Mon 114 1,0000 0,000000
Fri 199 0,8090 0,0279
Wed 230 0,9739 0,0105
Table II. CTQ number of transferred patients from short stay to home
The CTQ # short stay patients on other wards. During the measured period of 83 working days, 5680 patients were admitted to other wards in the same hospital, while staying less than four days. These patients were not all 5680 suitable for admittance on the short stay ward, since this ward is used to treat protocolled non-specialized care and not all 5680 patients underwent this. Furthermore, not all of those patients will be discharged before the weekend started.
Opening of the short stay ward in the weekend hours did not show potential, since the number of patients admitted to other wards during the weekend did not differ from the number admitted during the week (539 patients versus 666 patients). This will on the other hand increase the costs enormously, since the staff will be paid during the weekends as opposed to the current situation. Therefore, weekend closure is not a significant factor of influence.
We found that 99% of the patients can be admitted to the short stay ward if there were 21 beds only instead of 34 (see Figure 7.). That means that the short stay ward can be
downsized by a third. However, we have already shown the beneficial added value of a short stay ward, so based on strategical decision making this does not seem to be the better option.
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There were 666 patients of these 5680 on two surgical wards that already admit their patients to the short stay ward. So, the care for these patients is similar and potentially these 666 patients can be admitted to the short stay ward. Increase of the number of admitted patients can only happen when 1. the longer staying patients are treated in the beginning of the week as well as 2. are leveled out with respect to time of admission and discharge to overcome the peakload for staff as is depicted in figure 8. The factors that influence this are the planning procedure and the variation caused by planning in days of the week as well as hours of the day.
Based on the above, the decision is made by the upper management to optimally make use of the 34 beds available on the short stay ward. This means that patients from other wards that were admitted for four days or less were to be admitted to the short stay ward in future.
D. Improve
Next we will calculate in financial terms what the consequences are of improve the bed occupation by admitting more patients to the short stay ward instead of admitting them to the other wards.
We aim to improve the admittance of short stay patients to optimize bed occupation towards a 100% (34 beds). Firstly, the length of stay of the 910 patients (see table III. ) was used to calculate the number of available patients from other wards with comparable lengths of stay.
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This table showed that an additional 666 patients, i.e. 8 patients per day, from two other wards (of whom the patients are already treated on this short stay ward, ENT amongst one) could have been admitted to the short stay.
Figure 9. The bed occupation on the short stay ward can be increased by 73%.
The total financial benefits by admitting a patient to the short stay ward instead of the long stay (ENT) ward per patient are €72,50 per day (see financial appendix). The daily benefits for 8 additional patients : €72,50 * 8 = €580 and on a yearly basis the financial benefits of this improvement would be €580 * 250 = €145.000 .
E. Control
It has been said that the strength of the DMAIC is in the Control step. Measuring, recording and reporting data regularly to continuously monitor the overall process is mandatory. With this step we ensure a successful implementation of the above made recommendation in order to achieve and attain long-term success. The Control step furthermore is about the transfer of responsibilities.
As we have chosen the improvement of a strategical implementation we advise to measure the performance indicator of: the number of patients with a length of stay shorter than four days that are admitted to other wards than the short stay. Hereby we can control the mis-placed patients, check their records and evaluate the reason for misplacement. The strategic
Opmerking [E.A.3]: Rob, zou je en enegelse publicabele versie kunnen maken?
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upper management should be the one to address wards and medical specialisms if, for no valuable reason, their short stay patients are not admitted to the short stay. Valuable reasoning would be the need for specialized care. The project was ended by signing the discharge form.
22 Discussion
In this project, the Lean Six Sigma DMAIC methodology was used as a problem-solving tachnique that is known to be very efficient in improving organizational performance. In this study we found that the bed occupation on the short stay ward in a university hospital can be increased by 73%. We found that there is a large amount of variation in the planning of the beds. In the current planning procedure, the turnover of admissions and discharges contributes to the low level of bed occupation. The amount of turnover work for the nursing staff is not allowing an increase in bed occupation with the current planning. However, In the busiest week there were 14 empty beds measured. Improvement in planning will level out the workload, allowing more patients (73%) to be admitted. This will create more space for another 666 patients to be admitted to other long stay wards. Hereby, DMAIC was also used as a management method that can improve the organization in an orderly way, with the target being to reach optimal management. DMAIC gave structure and guidance to improving processes and productivity on the short stay ward in a university hospital. We have applied the DMAIC steps and appropriate analysis tools under each step, to analyze and improve key metrics of the short stay. Metrics were established and their outcomes were studied. A proposal was given to improve the business and reduce variation in the processes. The result is aimed at improved performance, fewer errors and increased efficiency and productivity.
Short stay in a high complex environment
A shorter period of hospitalization could reduce the risk of hospital-acquired infections, increase patient satisfaction and yield more efficient use of hospital beds (G. Damiani, 2011). Furthermore, the improvement of disease-specific clinical pathways will result in both cost reduction and a decrease in hospital stay for specific groups of patients (Muller, 2009; Rotter, 2008). A short stay ward could facilitate the bridging of pre-hospitalization phase and post-hospitalization phases, allowing the design of a single managed care plan covering the entire continuum of care for some chronic diseases(G. Damiani, 2011). Therefore, there will be a need for a short stay ward, even in a university Hospital.
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The short stay ward is a very suitable ward to treat patients with standardized care. As a general rule, standardization is an indicator of efficiency (Eric Just. Quality Improvement in Healthcare: Where is the Best Place to Start? Quality and Process Improvement). Process standardization is strongly associated with improved quality and efficiency of care (Bozic KJ, 2010). A multispecialty group at Mayo Health System initiated efforts to reduce variation in the clinical practice patterns of providers. The pilot initiative, which entailed standardization of a sliding-scale insulin protocol, served as a template throughout for reducing variance and enhancing safety (Rozich, John D., 2004). A standardized protocol may also be a cost-effective method for hospital managers and administrators to accelerate the socialization of nurses (Vardaman JM, 2012).
In a high complex care environment as a university hospital one might argue that there is no need for a short stay unit. But also in a high complex care environment, these patients will still need care that will take only a few days of admittance, as diagnostic procedures or repair surgery. This can be performed in the university hospital itself in a different unit, or one can choose to deliver the care in a different facility under governance of the university hospital. This form of regional service level agreements is currently being explored. In all scenarios the patients suitable for short stay care should not be admitted to the longs stay wards.
Leveling out the workload and improve planning
The amount of turnover work for the nursing staff is not allowing an increase in bed occupation with the current planning. As we said, the nurses cannot handle more patients because of the peaks during the day. The solution to this problem is not to ask workers to work faster or harder. Overburdening of people can be managed by Toyota Way Principle #4: Level Out the Workload (Jeffrey K. Liker, 2004). The Toyota Way is a set of 14 principles and behaviors that underlie the Toyota Motor Corporation's managerial approach and production system. Leveling out the workload is done by implementing a continuous flow featuring time-balanced process steps with very few peaks and lows. Comparable to the fable about the tortoise and the hare, “slow and steady wins the race.”
How can leveling out of the workload be achieved? Production control systems can be divided into pull systems and push systems. The basic mechanism of a pull system is that
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production at one level only happens when initiated by a request at the higher level. That is, units are pulled through the system by request. In case of push systems, production
activities are scheduled. As in our hospital. However, this push system only works when production is predictable and with fixed lead times. When variation is introduced, the system often cannot keep pace. As in our hospital. No literature exists on implementing pull control systems in healthcare. However, in daily practice, we do make use of this system. A pull schedule (agenda) could be kept by the short stay ward controlling the leveling out of the workload. To implement this pull control, managing the bed occupation by scheduling from the departments point of few based on the demand, we should deal with the OR-planning departments. In our hospital we have eight OR-OR-planning departments that are currently responsible for the planning of the patients on the short stay ward whenever surgery is scheduled. When implementing a pull schedule these planning departments should preferably work together or even merge. There will be huge economic advantage by merging these eight departments into one central planning department, however, giving up professional control of the individual medical doctor will require a mindset change of all caretakers in all hospital.
Quality improvement and cost reduction
Since the introduction in the Netherlands in 2006 of the market economy in healthcare costs have not decreased. Another approach to reduction of healthcare costs is needed. A
contribution to the possible solution is implementation of lean six sigma. For example, in 7 years the Dutch academic hospital that implemented lean six sigma (UMCG) made a gross financial saving of €30,000,000 by using DMAIC project charters. The cost of implementing lean six sigma (external consultant and materials) was €494,000. This represents a Return On investment of 98% and a net saving (excluding hospital staffing costs) of €29,506,000. The business case for cost reduction through improvement is depicted in Figure 10. Here it is shown that quality improvement implies cost reduction. In healthcare however, cost reduction failed. The quality of care is now being determined by the controller of the market economy, the insurance companies. They are however, not capable of determining quality of care and their primary focus is costs. The quality of care should be determined by the professionals in healthcare. Perhaps than the quality business case as depicted below will
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automatically lead to reduce costs. Until then, improvement projects driven by professionals are mandatory.
Figure 10. Quality improvement implies cost reduction through reduced re-work and larger volumes. Hospitals earn money by admitting and curing patients. Theoretically, treating more patients provides more income for a hospital and at the same time may reduce waiting times for patients before they are treated. However, in the specific case of the Dutch health care system where insurance companies pay the hospitals a fixed sum, more patients are not equivalent to more income. However, when more patients can be admitted to the short stay, availability on long stay wards is created. In a university setting, creating empty available beds for new patients on long stay wards is especially interesting, since the emphasis is on high complex care.
Six Sigma is known to improve quality, decrease the number of defects, reduce costs and satisfy customer expectations. Here we showed that leveling the work load and better use of beds in a short stay ward will benefit the organization. Will it also benefit the customer? Review of customer satisfaction in health care demonstrated that a relationship between expectation and satisfaction is not always as clear as we think it is and the concept expectation itself is not distinctly theorized as well (E. Batbaatar, 2015). By providing suitable, protocolled and standardized care the quality of the care will improve.
Furthermore, making better use of the beds on the short stay ward will improve planning an possibly also waiting times for the patients. This will have to be subject of further studies. Here we have translated process deliverables to patient satisfaction. A process deliverable
26
will have key characteristics that a patient would require, and Six Sigma is a tool or methodology that optimizes the consistency of those key characteristics.
Change as a result of a strategy
Here we have made suggestions for change and improvement of a process in a university hospital. The DMAIC is closed by a control step. This is important, since uncontrolled change can easily relapse into old habits. What is determined for success of a changed process? As Jensen (2000) used to promote: “change efforts should be guided by the sole purpose of increasing shareholder value”. He valued the success of an improved process as equal to the long term market value of the organization. He argues for a single objective instead of multiple ones. On the other hand, others have argued that the organization’s strategy should be determined for improvement processes. Only when there is a dialogue between all levels of the organization about what the added value to the strategy is, the chosen targets and process indicators can be understood and improved (Wouter ten Have, 2005). Daft (2004) defined strategy as follows: “A strategy is a plan for interacting with the competitive
environment to achieve organizational goals. [ …] goals define where the organization wants to go and strategies define how it will get there.” The board of directors is responsible for the development of the strategy (Zorgbrede governance code 2010;Van Schilfgaarde 2003). In the case of our study, the strategy for short stay patients has not been defined before the study was undertaken. Fortunately, there is an ongoing effort to develop a plan where to go with respect to the non-complex, standardized patient care in this particular university hospital. Only when this strategic plan has evolved, the proposed systemic change can be implemented. Systemic change according to Strikwerda (2015) was defined as change in all systems and domains; i.e. in all processes, management control, accounting and information transfer.
Conclusions
In healthcare, quality of care and costs amongst the most important parameters of health care outcome. Continuous improvement and a learning organization are both needed to
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provide optimum patient care. By use of the DMAIC lean Six Sigma we found that the bed occupation on the short stay ward in a university hospital can be increased by 73%.
The answer to my co-workers question is: never. He who stops being better stops being good (Oliver Cromwell). And he who stops being good is out of business.
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Acknowledgements:
Gabriella Balke-Budai and Rob Goedhart for data handling and prof dr Ronald .J.M.M. Does for guidance and supervision.
Shortened version of this manuscript Improvement of efficiency at the short stay
department in a university hospital. E.A. te Velde 1, G. Balke-Budai 1, R. Goedhart2, R.J.M.M.
32 Financial appendix
The direct costs per patient are 222,22 at the ETN ward, as opposed to 184, 82 euro on the short stay ward. This means that the direct costs per patients are -40 euro per patient on the short stay ward.
The labour costs per nurse is paid according to schaal A7 min 2156 – max 2921 for 1872 hours. A specialized nurse is paid according to schaal 8A min 2592 – max 3122 The labour costs of the attending physician present on the short stay is according to schaal 10 min 2592 – max 4111 Physician Assistant. The more specialized physician in training or resident (AGNIO) is paid according to schaal AA min 3250 – max 4486 This results in a financial benefit of 72, 50 euro per patient per day on the short stay versus long stay at the university hospital.
directe kosten FUNCTIE LONGEN 1 € 77,55 VHEM € 277,88 VINW VIG € 205,64 VLON € 257,45 VONI € 226,35 Ve vat/uro/nef € 254,75 DIV-1 € 246,05 VA KNO € 222,22 VA Kort verblijf € 184,82 VA Neurochirurgie/Ortho € 239,16 VA Neurologie € 169,91 VMPU € 273,71 DIV-2 € 213,46 Kinderkliniek 9b en 9c € 322,98 Poli KG € 132,07 VA V en G_8b en 8c € 257,24 DIV-3 € 228,55 HVC € 349,37 KLINIEK CL 4 € 194,78 Medium IC Cluster IV € 651,96 DIV-4 € 269,54 € 243,42 Matrix Gem.Kostprijs 2013 als waarden DIV-1 DIV-2 DIV-3 DIV-4
