“When you set out to design the optimal stay for patients with pneumonia or hip fracture, for example, you take out huge wait states that patients experience and you embed quality within the process.”
– Robbi Bishop
There is a misperception by some in health care that the lean management approach is applicable to administrative but not clinical or diagnostic issues. In fact, significant progress is possible in a wide variety of clinical value streams, and teams at Virginia Mason have demonstrated meaningful gains during the past year or so.
Teams have demonstrated that when the Virginia Mason Production System (VMPS) is applied to clinical value streams, significant reductions in length of stay – from 10 to 25 percent – are achievable.
“As we looked at length of stay before 2013, we typically looked at specific cycles of work – for example, the admission process, delirium screening process or social worker work flows. Quality improvements were seen, but we didn’t see significant improvements in overall length of stay for our patients,” says Robbi Bishop, administrative director, Kaizen Promotion Office.
In recent years, it seems every hospital in America is focused on reducing length of stay with an obvious focus on just that measure – how long a patient remains hospitalized. But what if you were to approach it differently? What if you were to focus on the perfect patient experience in the stay rather than its length? What if you were to say, as Bishop and his colleagues did, “Let’s design the optimal hospital stay for patients with a variety of diagnoses.”
Turns out that doing so not only improves quality and the patient experience, but flow in the hospital improves, as well, and the length of stay is shortened.
“When you set out to design the optimal stay for patients with pneumonia or hip fracture, for example, you take out huge wait states that patients experience and you embed quality within the process,” Bishop says.
Consider this example from last month. Bishop led a Rapid Process Improvement Workshop (RPIW) focused on patients with hip fractures. “We had an order set in the Emergency Department” where most hip fracture patients enter the hospital, “but nothing for the inpatient stay. For most of these events, we had an order set modified or built,” Bishop says. (In the process, he adds, an RPIW reduced time for building order sets from six months to six weeks!)
The kaizen work noted these patients are mostly older and typically have other chronic medical issues. As a result, the great majority are discharged to a short- or long-term skilled nursing facility.
“We found that while surgery was being done within 24 hours after the patients were admitted, we were waiting until after the surgery to talk with the patient and their family about post-discharge care plans,” Bishop says. “When we moved this discussion from after the surgery to before, we reduced the length of stay from 109 hours to 82 hours.”
This approach enabled clinicians to have a conversation early on to set expectations for the patient. It also gave social workers much more time to work on plans for care after the patient meets all their acute care goals.
Something important happened when the RPIW team focused on total joint replacement: they modified a visual aid for patients to help them clearly understand the pathway ahead.
“Because of the feedback we received from patients, family and our care teams, we decided that we would have a patient-centered visual for every clinical value stream, and that it would be written from the patient perspective,” he says. “We knew we needed to do a better job of integrating patients into the process and to make sure they understood what to expect and were not in any way confused.”
During 2013, Virginia Mason teams conducted 10 RPIWs on clinical value streams and the number this year will reach 17. A recent update on this work made important observations:
In 2013, the clinical pathway/value stream approach was started to address inpatient length of stay opportunities, integrate our patients into their care journey, and address any quality opportunities. The design included a robust unit leader/physician partnership along with the use of published literature as a way to integrate evidence based care. Early results reveal a median length of stay reduction of 23% for the 10 patient populations addressed in 2013. Patient feedback has been very positive in regards to the patient focused visual, and the events are addressing quality opportunities where appropriate.
Assessment: Our clinical value stream approach in 2013 has shown significant improvements in length of stay, patient satisfaction and quality. As we plan for the future, we will use feedback from event leaders, sponsors, process owners asking for more standards around the use of literature pulls, event scoping and use of data to help guide the pre-event data collection.
The update notes that future kaizen work will:
- Focus on specific patient populations or families of patient populations with similar inpatient care needs
- Focus on designing the optimal length of stay of our patients as a way of showing respect for their time and the overall cost of providing care.
- Address quality/safety opportunities when present
- Provide a patient focused visual that engages the patient and family and summarizes the critical milestones needed for discharge
- Identify the needed organizational support to implement the clinical value stream. This may include order set changes/creation, upstream or downstream process changes, etc.
- Incorporate evidence based care processes into the event.
- Identifies a standard process to conduct clinical value stream improvement events, including a standard metric target sheet.
How are you focusing on the patient experience to improve outcomes?