High Pressure PEX: Transforming the patient experience when every second counts

As shifting demographics and healthcare reforms put added pressure on hospitals, many are looking to improve processes to help them cope. Here’s how Moffitt Cancer Center responded to a looming bed shortage by putting the patient first.

Time is a precious commodity for the patients getting treatment at Florida-based Moffitt Cancer Centre and Research Institute and an extended hospital stay is typically not how they envision spending the time they have left.

Couple that with aging demographics –the UN Population Division estimates that 1 in 5 people are expected to be 65 or older by 2035 - and Moffitt Cancer Center realized that to meet increasing demand and improve patient satisfaction, they would need to reduce the average length of stay. Otherwise, they would simply run out of beds for the level of demand.

The looming bed shortage at Moffitt is just one of the problems facing hospitals up and down the country as shifting demographic and government healthcare reforms start to bite. Non-profit hospitals must spend a percentage of operating revenue (this varies from state to state – in Texas, for instance, it is 4%) on charity care for uninsured patients to remain eligible for tax exemptions on sales, property and income. With 30 million more people set to receive insurance when Obama Care comes into full effect in 2014, it will be harder to meet the benchmark, and tax exempt status will be under threat.

Adam Powell, president of Payer and Provider Syndicate, a Boston-based consulting firm for hospitals and health insurance companies explains: "Health care reform has the potential to decrease hospital revenues. The goal is to bend the cost trend, reduce the cost of health care, and that means reducing reimbursements. Health care reform also seeks to increase preventative care, keeping patients out of the hospitals. So it’s both decreasing volumes and payment rates."

For healthcare organizations such as Moffitt, the cost-saving benefits associated with process excellence provide a means of adjusting to these reforms. Process excellence in healthcare is often manifested as Lean, a methodology developed by Toyota which aims to improve process flow while minimizing waste. It has found prevalence in the healthcare sector for its role in delivering operational efficiency.

But the primary driver for process excellence cannot be traditional cost-cutting, many experts warn.

"Since 60 to 70% of a hospital’s costs are labor, typically, it’s tempting for hospitals to slash headcount when things get tight financially," writes well known Lean healthcare blogger Mark Graban. "This is a common healthcare response and Lean provides a great alternative to morale-damaging layoffs."

"Cost reduction is a common end result of improving safety, quality, flow, and other factors," he suggests.

That’s something that Moffitt Cancer Center – named amongst "America’s best hospitals" by US News & World Report – understands well. Process excellence has yielded numerous improvements at the center that benefit patients, staff and the bottom line. Establishing accountability for medical necessity checks eliminated $52,000 in monthly charges, for instance, whereas new scheduling guidelines freed up four treatment chairs for blood transfusions, reducing the average wait time from 3.4 to 1.5 hours.

But what about the looming bed shortage?

High Pressure PEX – Three Years On

Presenting recently at the PEX Week Europe conference, Moffitt’s Director of Process Excellence Ashly Mason offered a balanced appraisal of the center’s process excellence program, and whether they had managed to reduce patient length of stay to satisfy growing demand.

Their process excellence team started by evaluating the value stream – a six stage process that begins with patient admission, and ends with patient discharge and room turnover. This brought statistical improvement: room turnover response time improved by 61%, the patient checkout process saw notification delay improve by 41%, and discharge medications witnessed a turnaround time improvement of 50%.

But these "quick-wins," which targeted the end of the value stream, failed to reduce average length of stay between 2010 and 2011. More disappointingly for an institution of Moffitt’s integrity, which prides itself on incorporating the "voice of the patient," was the plateau in customer satisfaction levels.

In 2011, Moffitt changed tact, revamping its leadership, ownership and accountability, and methods of staff and patient engagement. One of the traditional pressure points in process excellence implementation – achieving buy-in from physicians who struggle to reconcile patient with process – was alleviated with a new, progressive Chief Nursing Officer, and careful deliberation as to when physicians should be involved in planning. It was management’s willingness to break free from the shackles of spread sheets and "go to the Gemba" that helped cement stakeholder buy-in. The change to infrastructure and communications was met with holistic focus on the value stream, which addressed proactive discharge planning and communication as key drivers behind the length of stay.

The outcome was fruitful – length of stay decreased 3% between 2011 and 2012, from 6.35 to 6.17 days, paving the way for 219 extra patient admissions and a direct margin increase of $1.7 million. The streamlined discharge process saw patient satisfaction levels reach an all-time high, from the 83^rd to 95^th percentile.

Mason puts the success down to the organization’s ability to "Moffittize" process excellence – which places a focus on outcomes, rather than rigid Lean methodology: "People feel like it’s more directly related to their process…they can get turned off if it’s from another industry."

She also credits the patient and family advisory program, "Customers and families sit on committees and project teams…either going through or having gone through the system. Who best to tell us what’s waste than the patients and their families?"

With admissions set to increase 4.2% year on year and additional beds a few years away, the challenge is to whittle down the necessary length of stay to 5.03 days by 2017 – a task that Mason acknowledges will be difficult.

Key though, even in the midst of healthcare reform, is to resist senior leadership’s cries for a cost-centric approach: "‘We have to remove 15-20% of the cost from the system in 5 years.’ That’s a good burning platform, but that can’t be what we focus on. We’ve been working with the leadership team to focus on the patient experience and removing waste…cost benefits will come."

It’s that bargaining, along with assuring staff that transformation and elimination of waste is not synonymous with job losses, that keeps Moffitt’s process excellence ticking over: "It is stuff – inventory, processes…not staff that must go," Mason concludes.

You can listen to the full Ashly Mason podcast on Moffitt process excellence here or watch a video of her presentation here.

Do you think more healthcare organizations will be turning to process excellence to sort themselves out? Have your say below!

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