Many hospitals are experiencing exponential growth in patient volume for digestive diseases. This results in increasing pressure for the delivery of endoscopic procedures. This, in addition to new guidelines from the Ontario Ministry of Health, including new colon cancer screening targets, placed a strain on the existing program at the McMaster University Hospital endoscopy unit.
Achieving new throughput targets was becoming more and more challenging and represented an acute short-term problem. With existing process and space limitations, the facility was unable to handle the increasing patient volumes. Unfortunately, this led to increased wait times for patients. The Digestive Disease Leadership Team decided to review and improve unit efficiency, patient care and increase capacity within one year.
There had been a number of similar reviews and improvement efforts made in the past, and, although recommendations for change had been tabled, for the most part they had not been implemented. This history created skepticism within and around the unit as to whether or not change could in fact be successfully implemented.
The team realized that the involvement and agreement amongst all of the hospital functions participating in the endoscopy unit was critical to realizing improvement opportunities, solutions and implementation. The team decided to experiment with a new creative problem solving approach (Simplex) which uniquely engaged all staff, including physicians in multi-functional teams. The strategy was to support and enable the teams to create and implement their own original solutions based on identified bottlenecks.
Multifunctional Steering Committee
A steering committee was established. It was made up of several physicians, nurses, clerical staff and administrators. All were representatives from each of the functions involved in implementation. The role of the committee was to participate in key facilitation sessions where facts were discussed, challenges defined and solutions selected. The Steering Committee convened at critical stages and all participants were actively involved in the decision making process.
The importance of this approach cannot be underestimated. For example, failure to engage key physicians in the decision making process often dooms the implementation effort. All of those participating in implementation must fully understand the situation and buy into it in order for the required changes to truly be implemented.
Simplified Process Flowchart
A simplified flow chart was developed to document the endoscopy process. It clearly describes the activities, responsibilities and, where appropriate, timing. In addition, the boxes were colour coded to reflect the different functional groups participating in the overall process. The primary application of the flow chart was to identify bottlenecks to patient flow.
Figure 6: Process flow performance data is collected to confirm suspected process bottlenecks.
Process Improvement Challenges and Selected Solutions
A process improvement challenge is defined for each confirmed bottleneck, expressed in the Simplex format: How might we? This wording helps the team to focus on the opportunity ahead, the desired result, rather than the blockage itself. Challenges are then assigned to sub teams who develop solutions for implementation.
The following changes were made:
Accelerate Procedure Room Turn Around Time
Challenge: How might we turn around the Procedure Room in less than five minutes while maintaining quality?
Currently, many procedures are finished ahead of schedule. As a result, the room can be cleaned and made available for the next patient; however, the patient is often still involved in their pre-work and not properly prepped.
Solution: Take steps to ensure that a prepped patient was always available as soon as the procedure room was vacant and cleaned.
Improve Recovery Room Availability
Challenge: How might we always have a recovery bay to receive a patient when they leave the procedure room?
The lack of patient recovery space was a critical bottleneck in the process. The previous practice had patients in the recovery room for at least thirty minutes before discharge.
Solution: Patients recover at different rates and a significant proportion of patients can be safely discharged much earlier.
Effective Slot Utilization
Challenge: How might we assign MD slots aligned to the work practices of each physician?
It was recognized that different physicians work at different rates and this was not accommodated in patient scheduling.
Solution: Match patient volumes with the individual physicians’ work practices. In many cases faster working physicians were able to see more patients than had been previously scheduled.
Following implementation of the planned changes, substantial improvements were achieved against the following metrics as displayed in the following chart.
Figure 7: Endoscopy unit performance metrics
In summary, the average time between the patient leaving the procedure room and a new patient arriving was reduced by 82% from about twenty-two minutes to four minutes and by 67% between patients leaving the Procedure Room and a new scope starting, a reduction (from 29 minutes to 10 minutes). The average time a patient remains in the Recovery Room was reduced by 32% (41 to 28 minutes). The weekly number of all cases handled increased by 33% and colonoscopy/endoscopy cases by 9%. The percentage of times that the Procedure Room has been turned around in 10 minutes or less has been increased by 80%, (from 18% to 88%).
A report card was developed to track the impact change was having on performance. It is a single page which documents four or five key measures to track results. These cards often incorporate the original baseline data, current performance data and the target performance goals. The report card helps the entire team monitor their performance resulting from change, relative to past, current and ongoing targets.
While it is risky to extrapolate the best practices from one endoscopy unit to another, a number of potential approaches were identified which may be applicable to other environments as follows:
- Organizing patients at the front end of each of their procedures so that the Procedure Rooms could support efficient turnover was critical to capacity utilization.
- A realistic patient schedule which recognized the unique practices used by different physicians was critical to completing the morning and afternoon sessions on time.
- The recovery time is a critical constraint. The decision to move from a standard thirty minute recovery after the procedure to a time which was dependant on an objective set of discharge criteria, enabled better utilization of the limited recovery resources without compromising safety.
Change Implementation Learnings
Implementing change in an operating environment is always a challenge and, unfortunately, can often fail. As a result of this innovation project, we gained the following insights about our change making process:
- Complete involvement of all unit process participants throughout the project is required to ensure quality decisions are made and to build commitment to implementing the solutions.
- Independent third party facilitation is vital for streamlined decision making and successful implementation.
- Collaborative creation of the “Simplified Process Flow Chart” significantly helps the team decide on the best strategic bottlenecks.
- The best opportunities for improvement are not always obvious or intuitive and require concrete data for confirmation.
- Timely group problem solving is required to eliminate implementation roadblocks and ensure tangible results are achieved.