WHAT IS GOLD STANDARD MANAGEMENT?

Gold standard management (GSM) is defined as

1. an edgy attitude and unrelenting commitment to the best;
2. a complete and thorough implementation of best-management practices in every department;
3. integration and unification of various management philosophies and schools of thought so that management is an integrated system rather than a group of independent components or disconnected programs;
4. specific management objectives and accountability that put work in the hands of competent people, give freedom to make change, expect results, use tough measures, and apply consequences; and
5. a requirement that all professional and technical staff implement their specialty's standards and best practices.

Using GSM, the management team eliminates management malpractice and violations of known best practices. Managers eradicate operational sludge and do not tolerate mediocrity.

Take the Domino’s Challenge

Domino’s made the guarantee that it could cook a pizza and deliver it to your home in 30 minutes or it was free. This began a revolutionary shift in customer expectations. Google taught everyone that it could find anything you want immediately and often for free. Customers used to want better, faster, and cheaper products and services; now they want everything free, perfect, and now, including healthcare.

This shift in customer expectations is hitting hospitals as well. If Robert Wood Johnson Hospital can offer a door-to-doctor guarantee, you might consider setting the same kinds of objectives:

• 30 minutes from door to doctor in the ED
• 30 minutes from “bed requested” to patient in bed
• 30 minutes from routine lab/radiology order to execution
• 30 minutes from discharge order to patient discharged
• 30 minutes from dirty room to clean room, dirty OR to clean OR

A Faster Lab in Five Days

In a large hospital, the response time of returning lab results to the wards was reduced by a factor of 10 simply by reducing the size of the transfer batch. It turned out that the transfer batch was determined by the size of the transfer trays.

- Boaz Ronen

One 2,400-square-foot hospital lab wanted to reduce turnaround times, which would reduce ED turnaround times and reduce LOS in the nursing units. Using pedometers, the hospital tracked lab worker travel time for a week. The hospital conducted what’s known as a 5S analysis (i.e., sort, straighten, shine, standardize, and sustain) to clean the area of 10 years’ worth of clutter (Figure 1.1) in four hours, then mapped the value stream (Figure 1.2) in two hours, and redesigned the workflow (Figure 1.3) in two hours.

Figure 1.1: 5S lab trash

Figure 1.2: Lab original spaghetti diagram

Figure 1.3: Lab redesign

Using Post-it Notes and a flipchart, the lab team was able to redesign the lab to reduce

• Staff movement by 54 percent (goal 30 percent)
• Floor space by 17 percent (goal 10 percent)
• Phlebotomist travel by 55 percent (21,096 feet to about 4 miles, ~1.5 Full Time Equivalent [FTE])
• Tech travel by 40 percent (2,304 feet, 0.15 FTE over three shifts)
• Sample travel by 55 percent (23,400 feet and 7 hours of delay per 24 hours)

Some changes could be implemented immediately; others required coordination to move machinery and recalibrate. The lab got a lot faster with less than two days of effort.

If you go to www.qimacros.com/webinars/webinar-dates.html, you can sign up for a free Lean Six Sigma for Healthcare Webinar to learn more about this Lean for hospital labs projects.

Denver Health rearranged workstations and equipment in the lab to reduce turnaround times for test results by 25 percent and saved $88,000. Overall, since starting its Lean journey in 2005, Denver Health has saved $54 million in increased revenue and cost savings.

Faster Medical Imaging in Five Days

North Shore University Hospital wanted to improve patient throughput on its CT scanners to decrease LOS and increase patient satisfaction. Average turnaround time (TAT) was 20.7 hours and varied from 8 to 34 hours. The target for improvement? 16 hours. Identified problem areas included

• Manual scheduling process leading to calls from nursing units
• Time-consuming prep and delivery of contrast medium
• CT tech travel to requisition printer (6,480 feet per day)
• Transporter availability and travel (432 feet per day)

After analysis of these various issues, the improvement team implemented several countermeasures:

• The requisition printer was relocated in between the two CT scanners, saving over 6,000 feet per day of unnecessary travel.
• Dedicated CT transporter was assigned.
• An Excel-based schedule was maintained in imaging and was viewable by all nursing units (this reduced phone calls and cancellations owing to improper patient prep or availability).
• Instead of a rigid schedule with no room for STAT orders, a “pull” system adjusted the patient transport and scan to accommodate just-in-time STAT scans.
• Contrast preparation was reassigned to the evening shift, refrigerated, and delivered during the transporter’s morning run for inpatients.
• One CT scanner was dedicated to complex procedures, and the second was dedicated to routine high-volume procedures to maximize patient flow.
• Staffing was adjusted to demand.

Results

• Average TAT fell from 20.7 to 6.45 hours.
• 200 additional inpatient scans were done per month.
• 60 additional outpatient scans were done per month.
• This resulted in $375,000 in additional revenue.
• Cancellations owing to improper prep dropped from 30.6 to 22.7 percent.

At Newton-Wellesley Hospital, radiology turnaround stood at 45 minutes. After examining patient and technician flow, the hospital found that technicians spent too much time walking around. By redesigning the work flow, turnaround times fell to 25 minutes, making the planned addition of another $500,000 x-ray machine unnecessary.

Massachusetts General Hospital’s proton beam facility was fully booked, or at least so the hospital thought—until it did a little analysis. By batching patients requiring anesthesia on the same day and scheduling an anesthesiologist for that day, throughput increased from 29 patients per day to 39 patients—a 33 percent increase.

A Faster Operating Room in Five Days

Copenhagen University Hospital wanted to reduce the time between surgical operations. The improvement team found that too much time (60+ minutes) was spent

• Investigating whether the patient got the required information from the surgeon (10 minutes)
• Unpacking individual sterile disposables (30 minutes)
• Waiting for missing devices (five trips per surgery)
• Waiting for the patient to regain consciousness to be transferred to recovery (20 minutes)
• Waiting for transport to recovery (10 minutes)

With some basic analysis, the team implemented countermeasures to save 60 minutes:

• Surgeon draws an X on patient’s wristband when the patient has been informed about the operation, allowing anesthesia to begin.
• Prepackaged sterile disposables replaced individual disposables, saving two nurses and 30 minutes.
• Standard checklists ensure that all materials are gathered before the operation starts.
• Anesthetic depth was adjusted so that the patient wakes up when the operation is finished.
• Hospital orderlies move patients to recovery immediately.

SSM Healthcare reduced operating room turnaround times from 30 minutes to 15.8 minutes.

A Faster Emergency Department in Five Days

In 2009, Press Ganey found that ED turnaround times still average over four hours, basically unchanged over the last decade. In 2006, the Centers for Disease Control and Prevention (CDC) found that 40 percent of hospital EDs were overcrowded. One Harvard study found that ED wait times rose 36 percent from 1997 to 2004.

Robert Wood Johnson Hospital in Hamilton, New Jersey (RJW), winner of the 2004 Baldrige Award, receives 50,000 patients a year. In 2004, RJW had ED turnaround times of

• 38 minutes for discharged patients
• 90 minutes for admitted patients

How is this possible? How did they do it? By systematically eliminating the delays between registration, triage, examination, lab, imaging, and discharge or admission/transport.

RJW’s 15/30 Program

In 1998, RJW offered a 15-minute door-to-nurse and a 30-minute door-to-doctor guarantee. Like Domino’s Pizza, if your nurse or doctor is late, your service is free! Patient satisfaction with the ED rose from 85 percent in 2001 to 90 percent in 2004. While payouts for this policy have been less than 1 percent of ED patients, ED visits doubled! This means that for 1 percent of the revenue, RJW increased ED revenue by 99 percent.

And because ED visits doubled, hospital revenue increased as well. Seventy percent of hospital admissions come from the ED. Faster turnaround times enabled the hospital to grow by over 10 percent per year, requiring the addition of a new nursing wing.

Results

• RJW was New Jersey’s fastest-growing hospital from 1999 to 2003.
• Mortality rates for patients with congestive heart failure (CHF) declined from 8 to 2.5 percent.
• Infection rates for things such as ventilator-assisted pneumonia (VAP) fell from 10 per 1,000 vent-days to only 2 per 1,000 vent-days.
• The cardiology market share rose from 20 to 30 percent.
• The surgery market share rose from 17 to 30 percent.
• Hospital occupancy rose from 70 to 90 percent.
• Employee satisfaction with benefits rose from 30 to 90 percent.
• Employee satisfaction with participation in decision making rose from 30 to 90 percent.
• Retention of nurses rose to 98 percent.
• Employee retention rose from 80 to 98 percent.

Faster patient flow means greater patient satisfaction, better outcomes, and more money!

Studies have shown that patient satisfaction begins to decrease when ED LOS exceeds two hours. There are two populations of patients who visit the ED, so let’s separate the emergent from the nonemergent cases and look at patients who get discharged.

If it takes only a couple of minutes to see the triage nurse, a few more minutes to get registered, and a few more minutes for a doctor diagnosis, then the total time spent on any one patient is perhaps nine minutes. So why does it take most EDs over two hours to handle each patient? Sure, some patients need lab work (11 minutes) and others need radiology, but most of those tests take less than an hour. We’re still looking at 35 to 60 minutes, not two hours or more.

If we look at admitted patients, they are taken into the ED immediately without having to wait. They see the doctor immediately. Tests are done STAT. Registrations are done at the bedside. Nursing floor bed assignments take only a few minutes. Nursing reports are fast. Transport to the intensive care unit (ICU), cardiac care, or Med/Surg floor takes only 15 to 20 minutes. These patients should fly through the ED, but they take longer than the discharged patients—two to three times longer. Sure, they have to be stabilized, but why does it take hours to get them into an assigned bed?

The answer, across the board, is delay. There is too much time between activities. The admission staff is busy, so patients have to wait. The triage nurse is busy, so patients have to wait. The ED is boarding patients who should be in a nursing unit, so patients have to wait. The ED nurse can’t reach the floor nurse to give a report, and vice versa. Neither nurse can leave to transport the patient. Beds are available but not staffed. And so on.

Imagine a Faster ED

Imagine an emergency room where patients walk in and something surprising happens:

1. They use the magnetic strip on their driver’s license, insurance card, or credit card to check in and register using a kiosk. The kiosk automatically takes pictures of all these IDs and uses the data to find the patient’s medical history, validate insurance, and so on.
2. Completing registration this way triggers a “pull” signal that brings the next nurse in the queue to collect the patient from the entry area and move him or her to an exam room.
3. Entering the exam room and gathering the patient’s vital signs triggers a pull signal for the next ED doctor in the rotation.
4. The doctor examines the patient with the nurse available and requests any tests or x-rays using a handheld device that kicks off the orders.
   1. The nurse draws any blood or other samples required and either (1) sends them to the lab for processing or (2) uses point-of-care testing to get results in 11 minutes or less. (Approximately 70 percent of patients require lab work.)
   2. The nurse transports the patient to imaging, if needed. (Approximately 30 percent of patients require medical imaging.)
5. Completion of the tests triggers a pull signal to the ED doctor to collect the results, diagnose, and recommend treatment.
6. The doctor then initiates treatment. Any “teaching” material or paperwork required is prepackaged and ready for the nurse to prepare the patient for discharge or admission.
7. Initiating admission kicks off a pull signal for a bed in the appropriate unit. If there isn’t enough staff in that unit to handle the admission, a pull signal may request an on-call nurse to come to work.
8. Instead of all being done manually, as most of this is now, it’s all carefully orchestrated and technically linked to minimize delay. Many of these activities can happen in parallel, not sequentially as they do today.

A discharged patient is in and out in 30 minutes. An admitted patient is in a nursing unit bed in 60 minutes. Of course, there will be exceptions—a rush-hour accident may tie up one of the doctors—but most patients are discharged. Finding ways to handle them in “one-piece flow” will improve ED performance dramatically.

Simply speeding up discharge and housekeeping of nursing unit beds can alleviate boarding and overcrowding in the ED. Empowering triage nurses to order x-rays for possible fractures without doctor involvement can accelerate diagnosis and treatment. Scheduling radiologists during the hours of highest trauma injuries (think rush hour and Friday/Saturday night) can accelerate ED throughput. Prepackaging common triage kits can accelerate treatment.

Simple Steps to a Faster Hospital

With all the hoopla about healthcare reform, there’s one huge missing piece—healthcare is going to have to get dramatically faster, better, and cheaper to help pay for the changes. Each of the nation’s 5,700+ hospitals must find ways to cut millions of dollars in unnecessary costs over the next decade. This may sound difficult considering that half of all hospitals lose money. Most hospitals exist on a 4 to 5 percent margin. But Lean can help hospitals start getting faster, better, and cheaper in just a few days.

One of the key principles of Lean thinking is to eliminate delays that consume up to 95 percent of the total cycle time (57 minutes per hour). If you’ve ever been a patient in a hospital emergency room (ER) or nursing unit bed, you know that there are lots of delays. Over the years, healthcare has made tremendous strides in reducing cycle time in various aspects of care. Outpatient surgeries are one example: Arrive in the morning, and leave in the afternoon. No bed required. But there is still lots of room for improvement.

Goal: Accelerate the Patient’s Experience of Healthcare

In any given “factory,” there are two kinds of time: work time during a process when actual work is occurring and elapsed time—the total time a process takes (work time plus any time spent on handoffs, waiting, batches, backlog, and so on).

- Ken Miller

Over the last decade, I’ve consulted with many hospitals on all kinds of projects. Perhaps the most powerful tool that can be applied immediately to start slashing cycle times, medical mistakes, and cost is Lean. And it doesn’t have to take weeks, months, or years. With the right focus and the right people in the room, it only takes a few days to find ways to speed up any healthcare process, which, in turn, will reduce errors and boost profits.

Every hospital seems to have the same problem: patient flow. This shows up in many ways:

• Patient dissatisfaction and physician dissatisfaction
• Emergency Department (ED) divert hours (ambulances diverted because of overcrowding), patient boarding in the ED, LWOBS (leaving without being seen), and four-hour turnaround times
• Operating room (OR) delays, cancellations, and long turnaround times
• Imaging delays, long turnaround times
• Lab delays, long turnaround times
• Bed management delays
• Late discharges
• Long patient lengths of stay (LOSs)
• Lost revenue

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What one element is critical to both patient flow and satisfaction?

Time—patient wait time leading to poor turnaround times and poor patient outcomes. Patient wait times are non-value-added (NVA). This non-value-added wait time is “baked into” existing procedures and facility design, but that doesn’t mean that it can’t be changed.

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Healthcare delivery often involves complex processes that have evolved over time and that are neither patient-focused nor clinician-friendly. When systems do not work well, healthcare workers resort to creating “workarounds,” adding additional layers of “patches” and “fixes” to poorly functioning systems.

- Christopher S. Kim, M.D