This is a third in a series of articles about how attendees of the two-day Lean Improvement Model for Health Care training apply what they learn to make improvements to their work environment. (See also: Part 1 and Part 2.)
“Attending Lean training made us more aware of the resources we were using in our lab and the complexity that goes into routine tasks that we do thoughtlessly on a daily basis. It has helped us to recognize, discuss, and develop plans to improve situations that have averted change,” reported one of the participants.
The one task that stood out was uploading EMG reports into the Epic system. The current procedure is manual, requiring a technologist to upload a physically signed document into Epic. In the age of digital technology, the inability to electronically sign documents which are then automatically linked to the EMR is rather unheard of. Nihon Kohden, the EMG system manufacturer, offers an HL7 Epic interface which allows this process to be completed electronically.
After attending the Lean training course, the team sought guidance from Operations Excellence, who assisted the team in developing a course of action. The plan would demonstrate the re-occurring labor and supply expenses and the potential for error inherent in the current manual process. The team operationalized the plan by developing a process map and conducting time studies. This information became the financial justification for purchase of the HL7 interface. The justification was presented to James Sherman, Neurology Clinical Department Administrator, who submitted the request for purchase.
The EMG team completed the following steps:
Step 1: Create a process map
Creating the process map helped the team identify all the steps required to upload the EMG report into the media tab in Epic and perform quality control that the upload was complete. Team members became quite efficient at this mundane task and were surprised to see how many steps actually went into this activity. The process map was also useful for identifying waste.
Identifying and eliminating waste is a fundamental Lean principle for making workplace improvements.
Eight categories of waste:
- Defect: anything incomplete or not done correctly the first time
- Overproduction: producing more than is needed by the customer
- Waiting: time spent waiting on items or tasks required to complete the customer’s request
- Neglected talent: underutilization of skills or human potential
- Transportation: moving things
- Inventory: having more things on hand than needed to do the work
- Motion: unnecessary movement of people
- Extra-processing: effort and time spent processing information or material that is not adding value
The flow chart below shows the process map. Looking at this, it is clear to see the potential for error. It remains a mystery to all how this manual process resulted in few upload errors. However during this improvement project a PSN was generated due to a patient EMG result scanned into the wrong MRN.
Step 2: Identify the problems
The PSN prompted everyone to remember a valuable quote from Lean training: “Blame the process, not the person.” The team started asking “why” questions to clearly identify the root cause of the problem, not just blame it on human error. When faced with a problem, it is human nature to jump to solutions. Solutions are generally easy to come up with, but are only completely effective if they resolve the root cause of the problem. Lean training taught the team to spend time defining the problem and taking time to search for the root cause of the problem. The EMG team identified several problems and each added waste to the system:
- Patient result scanned into the wrong MRN (defect)
- Reports not scanned into Epic media tab in a timely manner (waiting)
- Technologists working overtime to scan reports into Epic (neglected talent)
- File cabinets with paper reports overflowing with no room for expansion (inventory, motion)
The root cause of the problem was the manual upload of EMG reports into Epic. Replacing this process with an electronic system would resolve the problems and eliminate several categories of waste.
Step 3: Conduct time studies
Financial issues are always a concern, and the solution required the purchase and installation of a new Epic interface software application, HL7. Along with the purchase price, the initial setup costs needed to be considered. These include the extensive support and cooperation from the Nihon Kohden representatives, Health Care Information Systems staff, and the EMG staff during installation, system validation, and faculty and staff training.
To make this investment appealing, it was necessary to highlight the costs of waste in the current system based on the production of a paper EMG result and manual upload: time (physician, technical, and clerical), supplies (paper and toner), and space (paper filing system). Time studies were conducted to create an average time to perform, and James Sherman provided the salary and fringe benefit (SFB) costs. See table 1 below.
Table 1: Time studies
The average number of pages per report was calculated to determine a typical cost per report. See table 2 below.
Table 2: Supplies
The Joint Commission (JC) requires results be made available for 7 years. To meet this requirement EMG results were manually uploaded into media tab starting at Epic go-live in April 2014. Paper results for the current year are manually uploaded into Epic and the paper record filed for 1 year and then discarded. Archived EMG results within the 7 year JC window are verified in media tab to ensure electronic upload and are saved to an electronic file cabinet. The archived paper results are discarded. This process resulted in a time-fixed filing system. This system reduces the number of reports that go in, as well as the number of reports that are already in the cabinet. The photos below shows (a) the current amount of space used to store paper reports, (b) the current capacity, and (c) the new system. The new filing system will reduce the towers of file cabinets from four to one.
The amount of time spent manually tending to these reports surprised everyone. It was at this point that there was overwhelming evidence that the implementation of a new electronic process would have a positive impact on the lab.
Step 4: Present the findings
In order to present the findings in a communicable manner, a PowerPoint presentation was developed included all the figures shown above. Each slide included the details of each step, highlighting the factors that impact the purchase decision.
At present, administrative approval to purchase the HL7 Epic interface application software is under consideration. The EMG team is confident that the information gained in the Lean training course helped to formulate a plan and with the use of Lean tools (see below), a solution that will positively impact the efficiency and functionality of the EMG lab. This will in turn help the EMG service to continue to support the overall mission of UI Hospitals and Clinics to provide every patient with innovative care, excellent service, and exceptional outcomes.
Lean tools used on this project:
- 5 whys
- Time studies
- Process mapping
- Fishbone diagram
- Waste identification