Clinical Process Analysis Program: Critical Tools for ...

Clinical Process Analysis Program: Critical Tools for ...

Clinical Process Analysis Program: Critical Tools for Improvement and Costing September 19, 2012 UT CS&E Pre-Conference Workshop The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Introduction Program history Team introduction Organization of content Chronological use of tools by phases Outpatient & Inpatient Practice sessions using tools Handouts

The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center This is an organization chart said Dr. Deming (1947)! The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Healthcare Organization As A System (Deming: Production as a System p.4; Adapted by Paul Batalden, MD 1990) WHY WE DO WHAT WE DO HOW WE IMPROVE WHAT WE DO H.C. ENVIRONMENT

COMMUNITY NEED PLAN TO IMPROVE VISION DESIGN AND REDESIGN CUSTOMER KNOWLEDGE OUTCOMES MEASURES Operations SUPPLIERS

I N P U T S PROCESSES O U T P U T

S CUSTOMERS HOW WE PERFORM OUR SERVICES The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Satisfaction Clinical Outcomes Finance MD Anderson Cancer Center as a System (Based on W. Edwards Deming Production as a System)

2. HOW WE IMPROVE WHAT WE DO Vision: Making Cancer History Plan to Improve: Adapted From: A Framework for the Continual Improvement of Health Care. Batalden PB. Journal of Quality Improvement Vol 19 No. 10 1993 Needs of Society Relative to Cancer

Profound Knowledge Applied to: Education Patient Care Research 1. WHY WE DO WHAT WE DO Needs of Cancer Patients and Families Design and Redesign

Processes Staff Equipment Supplies Partners Etc. I N P

U T S Education Patient Care Research 3. HOW WE PERFORM OUR SERVICES The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center O U T P U

T S Outcomes = Valu Costs e 4. WHAT WE DELIVER Clinical Process Analysis Program The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center

Clinical Process Analysis Program Process Flow Chart, Direct Labor Cost & Opportunities for Improvement Participants: Clinical Lead: Designated clinical point person for the project Content Experts: Frontline staff Clinical Leadership: Clinical Administrative Director; Center Business Manager; CPA Team: Clinical Process Analysis Team, Nurse Manager; Medical Director; Quality Officer Performance Improvement SOT: Senior Operations Team The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Case Study: General

Outpatie nt Center The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center What is it? Why is it used? When is it used?

What does it look like? The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center CLINICAL PROCESS ANALYSIS Center Name: ___________________________________ Data Source Outpatient Data Diagram Service Activity Type

Total Volume FY10 Thoracic Medical 60% CARE (scheduling) Thoracic Surgical / FY11

Pt Acuity Median New Patient 12% / 13% Level 4 85.57% Consult 4% / 4% Level 3 64.59% Follow-up

84% / 83% Level 2 82.80% Procedure 0% / 0% NA New Patient 12% / 11% Level 4 79.58% Consult

22% / 25% Level 3 78.94% Follow-up 65% / 65% Level 2 74.16% Procedure 0% / .03% NA

New Patient 0% / 0% NA Consult 99% / 99% Level 1 90.97% Follow-up .9% / 1.4% Level 1 88.89%

Procedure 0% / 0% NA 30% Thoracic Radiation Ocology 10% The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center

Page 1 CLINICAL PROCESS ANALYSIS Center Name: ___________________________________ Location /Data Source Metrics Inpatient Data Diagram Service Admission Type/Input Direct Thoracic

Medical From OR Output Home ICU OR From ICU Outside Facility From Center Morgue

Direct Home Avg. Daily Census Average Acuity Unit 7P Avg LOS (Enterprise Information Warehouse / EIW) Avg. occupancy rate

Thoracic Surgical Avg. # Admissions From OR ICU OR From ICU Outside Facility From Center Morgue

Direct Home Avg. # Discharges Thoracic Radiation Oncology The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center From OR ICU OR

From ICU Outside Facility From Center Morgue Page 1 PACU Data Diagram DATA DIAGRAM The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center

Practice Session Develop a Data Diagram for your clinical area using either the Outpatient Template or the Inpatient Template Time = 10 min Questions? The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center What is it?

Why is it used? When is it used? What does it look like? The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Menu In-Patient The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center

What is it? Why is it used? When is it used? What does it look like?

The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Blueprint Outpatient The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Blueprint Inpatient The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Blueprint Inpatient The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Blueprint In-Patient The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center

Practice Session Build upon the Data Diagram you developed earlier by indicating which service/activity type or input/output you will focus on. Using the Menu Template for either Outpatient or Inpatient, select the rooms or activities that take place in your clinical setting. Develop a Blueprint for your multidisciplinary workgroup to use when building the process flow chart. Time = 10 min Questions? The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center

Case Study: General Outpatie nt Center The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center

The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center What is it? Why is it used? When is it used?

What does it look like? The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Rule of Thumb: A great Process Flow Chart is: Chronologically correct Mathematically accurate Artistically simple The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Uses for Process Flow Charts

Identify opportunities for improvement (OFIs) Calculate direct labor costs Orient new staff Standardize processes Educate and inform patients Select new electronic nursing documentation systems The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center MARKERS BUTCHER PAPER

INVISIBLE TAPE STICKY NOTES The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center JOB CODES: Employee positions linked to salary groups The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center NOTE: Employee doing the activity is in boldface The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center

If all perform the activity equally: - Rectangle is white - Use and between each NOTE: Pharmacy is lightface because it isnt part of the inclusion criteria. If different people within the same job code perform the activity at different times: - Rectangle is color-coded to job code - Use / (meaning or) The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center

If different people perform the activity at different times: - Rectangle is white - Note percentages and utilize / (meaning or) The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center

Weekly Interview Meetings Facilitated by Clinical Process Analysis Team (CPA Team) Attendees: Clinical Content Experts, including Clinical Lead(s), Frontline Staff, and Clinical Leadership (i.e. CAD) Leadership facilitates staff attendance at the appropriate weekly meetings

Leadership promotes psychological safety, which encourages staff to share reality of current processes CPA Team creates process flow charts from the weekly meeting interviews Clinical Content Experts review charts each week and provide feedback/corrections to CPA Team Updated chart is utilized at the next weekly meeting, and so on

The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Next Steps Capture the voice of the patient Associate processes with management data reports Capture variation The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Patient comments accessed here The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center

The final process flow chart includes: The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Practice Session Using the Case Study handout, create a process flow chart. Utilize flip charts, markers and sticky notes! Time = 15 min Questions? The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Case Study:

General Outpatie nt Center The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center What is it? Why is it used?

When is it used? What does it look like? The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Transcription Spreadsheet JCs 01111 02222 01111 02222 01111 01111

01111 01111 03333 04444 03333 04444 01111 03333 04444 02222 01111 JC Grp Page Sequence Activity RN 7 1 RN & PSC & Pharm review order in EMR

PSC 7 1 RN & PSC & Pharm review order in EMR RN 7 1 RN & PSC & Pharm review order in EMR PSC 7 1 RN & PSC & Pharm review order in EMR RN 7 2 RN page MD/MLP RN 7 3 RN page MD/MLP RN 7

4 RN looks for MD85% / MLP15% in the area RN 7 5 RN & MD 85% / MLP 15% discuss clarification MD 7 5 RN & MD 85% / MLP 15% discuss clarification MLP 7 5 RN & MD 85% / MLP 15% discuss clarification MD 7 6 MD85% / MLP15% enters new order or new order MLP 7 6 MD85% / MLP15%

benters a l t RN 7 7 EC RNienters rec clarification order (EOS) d f MD 7 st 8oMD 85% / MLP 15% verify and signs order o C MLP otal7 8 MD

ity85% / MLP 15% verify and signs order v i T t c PSC transcribe new order (EOS) des the 77 a 109 PSC o c e RN RN acknowledges

order t a ob jo e estim s tim babilitie o pr Prob Time Exp Time 1 2 2

1 2 2 1 2 2 1 2 2 0.1 2 0.2 0.0001 2 0.0002 0.0015 7.5 0.01125 0.1

3 0.3 0.085 3 0.255 0.015 3 0.045 0.07225 3 0.21675 0.01275 3 0.03825 0.015 5 0.075 0.01275 3 0.03825

0.00225 3 0.00675 1 5 5 1 5 5 TOTAL TIME: 19.18645 The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Avg Hourly Rate (AHR) 48.00 15.00 48.00

15.00 48.00 48.00 48.00 48.00 142.00 60.00 142.00 60.00 48.00 142.00 60.00 15.00 48.00 Avg per minute

0.8 0.25 0.8 0.25 0.8 0.8 0.8 0.8 2.366666667 1 2.366666667 1 0.8 2.366666667 1 0.25 0.8

Direct Labor Cost 1.6 0.5 1.6 0.5 0.16 0.00016 0.009 0.24 0.6035 0.045 0.512975 0.03825 0.06 0.090525

0.00675 1.25 4 11.21616 Total cost = $11.21 per patient Transcription Gives an accurate representation of how much time a process takes and how much it costs The calculations take into account the probability of activities occurring Gives a clear picture as to how staff is being utilized Provides a good quality check of data from the

process flow charts The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Costing Direct Labor Costs The portion of the total cost of the fulfillment of a service that is associated with salaries, benefits, taxes, and other expenses related to the personnel needed for the process. The CPA program only provides data to calculate the Direct Labor Costs The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center A good costing system tells you which areas are worth addressing and gives you confidence

to have the difficult discussions with medical professionals. - Dr. Jens Deerberg-Wittram, Schon Klinic The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center When the process is improved, the transcription can be used to discover the savings in direct labor costs and time. The example below illustrates how identifying an opportunity for improvement and streamlining the process can save on time and direct labor cost. The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center

Below is the transcription prior to the improvement. The opportunities for improvement are highlighted and illustrate which entries will be removed or replaced. Total time per patient : 19.19 mins Total direct labor costs per patient: $11.21 The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center This is the transcription after the improvement is made. You can see the difference in the total expected time and the direct labor cost. Total time per patient : 15.175 mins Total direct labor costs per patient: $9.10

The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Summary What is it? Why is it used? When is it used?

What does it look like? The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Opportunities for Improvement (OFIs) The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Summary Report Report for Executive Leadership with a summary of: Direct labor cost OFI list Program evaluation Recommendations

The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Workshop Wrap-up Electronic copies of slides and resources Blank templates Email questions to Jessica Melchor @ [email protected] The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center Conclusion Its up to us Flood the Court! The Office of Performance Improvement, 2012 The University of Texas MD Anderson Cancer Center

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