CAHIIM Standard Assessed:? Subdomain VI.C.? Work Design and Process Improvement Construct performance management measures (Bl

Instructions:

Introduction:  College Community Hospital (CCH) is a 200-bed facility offering adult medical, surgical, orthopedic, and psychiatric care.  The hospital provides a full range of diagnostic and therapeutic services, including CT and MRI scanning and an eight-bed intensive care unit.  The 200 beds are distributed over six inpatient floors:

3A Acute Medicine

3B Diagnostic Medicine

3C Intensive Care

4A Acute Psychiatry

4B Orthopedics

4C General Surgery

One year ago, faced with decreased patient and staff satisfaction and rising costs, the management of CCH adopted a Total Quality Management strategy.  They formed a Quality Council and chartered several performance improvement projects.  Over a nine month period, projects were successfully completed in Dietary, Nursing, Psychiatry, Materials Management, Pharmacy, Health Information, and Outpatient Surgery,  they are now ready to begin the second round of projects.

One major source of dissatisfaction for physician and nursing staff has been slow turnaround time (TAT) for laboratory tests.  The lab performs about 3000 blood tests per week, the most common being CBC (complete blood count), serum electrolytes (sodium, potassium, chloride and CO2), BUN, a kidney function test, and blood sugar.

Given the high level of complaints about slow lab test turnaround time, the Assistant Administrator asked the Quality Council to initiate a Performance Improvement project team to tackle the problem of improving the number of tests completed within the hospital standard.  The Quality Council agreed, chartered a team, and asked the Assistant Administrator to act as Team Leader.

The Assistant Administrator was familiar with Total Quality Management concepts and recruited a team, including the Transport Supervisor, who had recently attended a class in PI Methods and Tools.  When all the recruiting was done, the team members were:

Lotta Paper, Assistant Administrator – Team Leader

Tom Trotter, Transport Supervisor – Quality Advisor

Beth Harrast, Floor Secretary, 3A

Harry Hiteck, Day Supervisor, Lab

Sam Drawit, Day Phlebotomist

Steve Spinner, Evening Lab Tech

Cathy Filer, Health Information Management

Problems with scheduling the team meetings made in impossible to include a representative from the lab night shift.

Now, it’s time for the first team meeting.  Use your imagination and “pretend” you are Cathy Filer and you are attending this meeting!  Notice the personalities and behavior of each of the different team players.

———–CURTAIN UP——————–

Lotta:  First, I want to thank you all for volunteering for this team.  I think we have…..

Sam: (interrupting)  I wouldn’t exactly say we all volunteered.  In fact, I’d say I was drafted.

Lotta:  Well, I suppose some of you were picked.  I asked the managers for people who really know what goes on in this process.  So, you’re the experts.  And I asked Cathy Filer to join us because she may be able to help us to use the EHR system more effectively to help with this improvement opportunity.

Cathy:  I hope I can help!

Lotta:  Let me describe the problem.  We’re getting too many complaints about long turnaround times for lab tests – I mean from the time the physicians decide blood work is needed until the time the results are available to them.  Harry helped me pull some data together that will give us a picture of how big the problem is.  Everyone take a look at your handout.

Harry:  This bar chart shows the percent of tests that got done within the standard for the past year.  The average is about 84%.

Beth:  What are the standards, anyway?  No one ever told me there were standards.  I thought everything was stat, stat, stat!  I know I spend a lot of time calling down to see when results are going to be available.

Sam:  Maybe that’s because we’re not making the standards all that often, whatever they are.

Tom:  Let me explain these standards.  When the doc’s fill out the request, they indicate whether it is STAT, Urgent or Routine.  There are different turnaround time standards for each priority.  STATs are 2 hours, Urgents are 6 hours and it’s 24 hours for Routines.  The times are from when the test is ordered to when the results are available to the doc.

Steve:  Well, whatever the standard is, I know the problem isn’t the time we take to actually do the test.  We’ve been measuring our turnaround time within the lab for more than a year now.

Harry:  Steve’s right.  We did have some problems in the lab a couple of years ago.  We had some pretty ancient equipment.  But, we were able to replace most of that last year.

Cathy:  Well, that is great to know.  Since we already know that the turnaround time for actually doing the test, and I am assuming we can show data to back that up, then the team can focus our time on other parts of the process.

Sam:  I don’t know why we need a team to solve this one.  It’s pretty obvious to me that you guys may be able to do the tests quickly, but you leave specimens sitting in your receiving window for long times.  You probably measure your own turnaround time from when you take the specimen from the box, not when it gets there.

Steve:  That’s not true.  If you want to blame somebody, just last week, I noticed that the messenger service left results in our out box for more than an hour before picking them up.

Harry.  That’s right.  I think there are just a few “bad apples” around here, including in the lab.  I’m looking into that now.  I’ll find them……I have my ways.

Beth:  (to Tom)  Tom, we’re not supposed to be going right to what we thing the solutions are, are we?  Or finding ways to blame other people?

Tom:  (with a sigh) Beth’s right.  What we have to do is see if we can find out what’s wrong with this process.  We have to get out of the habit of thinking it’s always someone doing something wrong.  So, the first thing we have to do is to make a flow chart showing how this process works.  Then, we’ll think about what could be causing the problem of long turnaround times.  We’ll have to test our theories and collect data and make sure we find the root cause.  Until we do all that, we won’t have much of a chance of solving the problem for good.

Steve:  Boy, that sure sounds like a lot of work.

Lotta:  That’s why we’re here.  We’ll learn a lot and have some fun, too.  But, we’d better keep an eye on the ground rules we put together.  That will keep us focused on the problems, rather than on blaming others.

Tom:  OK, let’s get to the first step – flowcharting this beast.  You folks tell me the steps in the process and I’ll write them on these poster size Post-Its and stick them on the wall.  Then when we think we have all the steps we’ll move the Post-its around and put them in the right order.

Lotta:  Sounds good.  So, where does this process begin?  What’s the starting point of our flow chart?

Beth:  Well, here’s the doc, making his rounds or checking a patient.  He decides that some kind of test is needed and writes the request….sometimes the nurse writes the order and has the Doc co-sign it…..and whether it’s STAT, Urgent or Routine is written right on the order.

Cathy:  How does he write the request?  On a paper request sheet?  Are we using the Order Entry option in the EHR?

Beth:  No, they write it on a request slip.

Cathy:  That is good to note.

Steve:  You know, I think the doc’s overdo it on the Urgents.  I bet that plenty of the Urgents could really be Routines.  Maybe they’re in a big hurry to get out of here, so they make it an Urgent.

Harry:  Well, 24 hours is a long time to wait for a Routine.  Maybe the doc is making rounds in the afternoon and would like to have test results back for the next morning.

Beth:  Sure, that happens.  But, that’s not really unreasonable is it?  Maybe the standards should be tighter.

Harry:  For pity sakes, we’re not meeting the standards we have now.  I think the standards are set by the Patient Care Committee.  They’re all docs and you know they’ll just want to tighten them up if we bring this to their attention.

Beth:  Maybe so….but, I think we should look at the standards.  I wonder what that standards are at River Valley Medical Center.

Tom:  Hold on, hold on.  We’re supposed to be flowcharting now.  These are good thoughts, so let’s write them down in our idea log and make sure they get included with our minutes so we don’t forget them.  Let’s get on with this process.

Lotta:  Well, the requests go to you, Beth, don’t they?

Beth:  Right.  I stamp them with the patient’s name and medical record number.  Then I put them in the floor out box for lab pickup.

Steve.  The Routines go into the box, but you call us on the STATs and Urgents.

Beth:  That’s right.

Sam:  Then the lab notifies me and I go up, pick up the request and do the draw.  That’s assuming the patient is there.

Lotta:  What do you mean “assuming the patient is there?”

Sam.  Just that.  Sometimes I go up and there’s an empty bed.  Maybe I was given the wrong room numbers, or maybe the patient is visiting Radiology or PT, or whatever.  There’s nothing like having a STAT order and you can’t find the patient.

Lotta:  So, what do you do then?

Beth:  Usually, he comes over and harasses me – like I’m not busy enough already.

Tom:  OK, let’s put that on our chart as a problem.  If it happens fairly often, it could be part of the turnaround time problem.  But, let’s say the patient is there.  You do the draw, right?

Sam:  Right.  Then I take the specimen down to the lab and put it in the in box. (Under his breath)…..Where it grows old.

Steve:  OK Sam, I heard that.

Tom (intervening) Everyone did.  Let’s keep one eye on the ground rules until we get used to working as a team.

Harry.  The lab people are always checking the in box and, when there’s a specimen, we take it, set up the equipment and do the test.

Steve:  We put the results on the form and put it in the out box.  The messenger picks up the results when they come by on their rounds, and takes them back to the floor.

Beth:  When I get them , I put them with the chart and flag it.  Usually, if it’s a STAT, I make sure the doc knows the results are there.

Cathy:  OK, that sounds like the whole process, except when do the results get put into the patient EHR?

Beth:  We don’t.  The results get sent down at discharge with the rest of the paper chart and I think they get scanned.  I’ve seen scanned result slips before.

Cathy:  OK, another thing for me to think about.

Lotta:  OK, let’s get to work flowcharting this process.

——————-CURTAIN DOWN———————–

Assignment Instructions:

You will create a Team Charter for this case scenario.  Use the information in your Lesson to guide you through the process of creating the charter and use the information and people in this project packet to complete the charter.  Your charter must include:

 Team Name

Problem Statement

Goal Statement (a.k.a.: Aim Statement or Mission Statement)

List of Benchmark time standards

Team Members

Proposed start and end date

Benefits of the project

NOTES:

Your problem statement should be customer-focused, performance-related, and stated in measurable terms.  It should not imply a solution or a cause!  Here is an example:

“The current process for delivery, maintenance, storage, and purchase of pump controllers is fragmented and inefficient.  The result is wasted staff time, lack of available functioning equipment, inappropriate use of space and frustration on the part of the customers.”

Your Goal Statement should also be stated in measurable terms.  The statement should show a clear target for improvement.  For example:

“Pump controllers will be available in proper working order within 10 minutes of request from the floor 95% of the time, beginning in November 1992.

This goal statement offers 3 points of measurement for success.  1.) There is a minute goal, 2.) There is a goal for how often, and 3.) There is a timeline for reaching the goal.

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The Quality Improvement Team and Project Management

Performance improvement teams involve a lot of people and they are time consuming and therefore expensive. It has been found that in healthcare, PI activities do not ALWAYS require a team approach. We should not automatically assemble a team to make corrections; we should first decide if it is an improvement opportunity that requires the team approach, or if it is just a matter of further education and training. Three typical approaches to the PI process are a blitz team, an educational training program, and functional or cross-functional PI team. Let’s look closer at each of these.

Blitz Team

Leaders of an organization may decide that they already have all of the facts and data they need about an improvement opportunity. A Blitz Team is put together for issues that can be fixed quickly without a lot of research or data gathering. Typically, individuals are gathered who are very familiar with the process to be improved, and the team can quickly plan a new process or process updates and take steps to put the new process into action.

Training

Not all improvement opportunities need a full team approach. If it can be decided that education and training will likely be all it takes to improve a process, then there is no need to spend the time and resources to put a team together and go through the lengthy PI process. Instead, training can be planned and conducted by HR or by a manager in the department involved with the process.

Functional and Cross-Functional Teams

When it is necessary to put a team together for the PI process, that team may be functional or cross-functional. A functional team will consist of members from just one department. Think of a department as “a function.” So, the improvement opportunity is one that only affects that department. However, if the issue effects multiple departments, then the team should be cross-functional, meaning that the team will consist of staff from each of those departments.

FUNCTIONAL TEAM

Staff from a single department or service area

 

 

CROSS-FUNCTIONAL

Staff from multiple departments or service areas

Effective Teams

How do we ensure that these teams are effective? First, the team must know what is expected of them throughout the process. Teams are most effective when the members experience team problem solving as part of the organizations culture. If they live it and see it every day, and it is modeled by the leaders of the organization, then the team members will be better able to problem solve within the team structure. As with all teams, attitude is everything. It is best to choose team members who will have positive attitudes about what the team is out to accomplish. It is also very important that members chosen have an interest in the process to be improved, because they work closely with it in their daily jobs. As for team size, it seems to be most effective to have around 8-10 members.

Here are some questions to ask when trying to decide who should be on the team.

Which departments or disciplines are involved in the process?

Who are the customers of the process?

Who supplies the process? (who provides a product or service that begins the process to be improved)

Team Roles

Team Leader: The Team Leader is the organizer of the team. They are responsible for the teams work and should be sure that the new process will meet customers’ needs. The leader chosen should be well respected and able to take the initiative to move the team forward toward their goals.

Team Facilitator: The Team Facilitator acts as the advisor and consultant to the team, so they should know the PI process and QI tools. The facilitator trains the team about the PI process and helps them work through the process. There isn’t always a Team Facilitator, but there should always be a Team Leader.

Team Member: The team members are all of those who participate and make decisions and plans. They identify opportunities for improvement. Throughout the process they help to gather, prioritize and analyze data and then share knowledge, information and data that pertain to the process. Their input is very important, because they are the ones who are closest to the process being considered.

Team Recorder/Scribe: The team recorder does all of the writing, notes, and documentation for the team. They should be someone who likes to write, can be committed to getting documentation done quickly, and will keep the group supplied with all of the information that they need.

Team Charter

Once the team has been established and everyone knows what their role is, it is time to put together a Team Charter. The team charter is basically a summary of everything the team has been charged It will include timelines and deadlines and any restrictions such as perhaps a budget, or time restrictions for example. If the team gets off track for any reason, the team leader can direct them back to the charter for a reminder of the direction they should be going.

Some Team Resources

An important part of the PI team is the Mission Statement, the Vision, and the Value Statements. These are guiding principles for the team and should be established in the very first team meeting.

Establishing ground rules for the team will help to make things go more smoothly. The ground rules are about discipline. They set up the expectations and inform each member of the accepted behavior and their role in making the team successful.

Some items for ground rules might be:

Attendance

Time management

Participation

Communication

Decision making

Documentation

Room arrangements

Cleanup

Team Success:

The success of the team will depend, in part, on the interactions of the team members and the communication in the meetings. The team leader may have to step in to help with some of the team interactions. All members must use good listening and questioning techniques. It will take practice and patience to deal with conflicting personalities. Questioning techniques can be used to direct the group interactions in a positive direction.

Just as you are seeing in your course project, conflicting personalities and attitudes will often come into play in any team situation. Hopefully the team leader will be able to smooth over some of the tensions and to redirect conversations that get off the topic and take a negative turn. If dealt with correctly, most of these issues can be overcome.

The Project Life Cycle

As you can see, project management is a complex and important task. There are proven ways that projects should be successfully managed and experience in project management will certainly help to bring a project from start to end with the best results possible.

 

TYPICAL LIFE CYCLE STEPS

Initiation – opportunity for improvement is identified

Sponsorship – by top leadership

Team Member Selection

Mission Statement – a first priority

Planning

Design

Execution

Closure

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