Transcript Document
PATIENT TRANSFER REPORTS ZEN SIGMA TEAM – PROGRESS REPORT Kawa Shwaish, Hayzel Criollio, Kulbhusian Sinha, Fatih Yilmazer Devin Leibert, Amy Nguyen BACKGROUND • UPMC’s Patient Transfer call center facilitates provider-to provider communication in order to assure bed assignment for patients. • UPMC determined that this was a problem when mgmt system was producing unuseful or incomplete reports. D M A I C • Define • Measure • Analyze • Improve (make recommendations) • Control (suggestion for how to control) D PROBLEM AND DEFECT • Problem Statement: The reports generated by the patient transfer system include significant inconsistencies in the data which reduces the reliability and usefulness of the report. • The Defect: Missing or inaccurate data in daily report to case managers DEFINE D • Objective • Understand the extent of defect and the transfer center business processes contribute to the defect. • Identify possible changes within the transfer center that can reduce the defect. • Projected Benefits • Metric • Area of Focus D LEVEL 1 PROCESS MAP MEASURE M • Data Collection • Observation • Meetings and phone conferencing • Files (csv, pdf, excel) • Email • Paper forms and templates • QA of two weeks of reports • Given vs. Calculated Shift data (pdf & excel) Annotated reports (email & excel) System data dump (csv) Consolidate into Database M MEASUREMENT SYSTEM ANALYSIS • Where is the data coming from • How reliable is the data • Assumption and Concerns • The QA process performed by the case managers is fairly accurate • The data is not sufficient to run statistical analysis such as regression and control charts • The four hospitals selected are representative of the 24 hospitals in the network • Data related to # of calls per coordinator does not include calls they might have processed to other hospitals M SHIFT DATA M DATA COLLECTION • Transform to unique shifts • i.e. If shift end is after midnight add a day • Cross reference to identify coordinators • Coordinator • Start time • End time M DATA COLLECTION • Linking the different data sources • Annotated report • Data dump • Unique shifts M DEFECT DETECTION • If not marked ok by coordinator • If coordinator missed the fact that there is no time stamp • If elapsed time was negative • IIf(([Sheet1].[cs_status_id]=2) • And (([sheet2].[comments]<>"OK ") • Or ([sheet2].[Bed Assigned] Is Null) • Or ([Calculated Elapsed Time]<0)),1,0) • AS [Defect of completed] ANALYZE A • Fishbone Diagram (start from the flow chart) • • • • • • Receiving Call Identifying Availability Conferencing Dr.s Conferencing Nrs. Data entry Report generation FISHBONE DIAGRAM Plant/Technology Procedures Computers Systems e s g min tat iv pe , re es tim Wa it s a rd nd sta Missing or incorrect data Aging workforce etc . all gic en try olo hn ata nD ow People sd Wo rk for c en ot va by ed ue ca us Policies Lack of typing skills tec ryin tio n gs be hif ts twe en Varying shifts ntia dif fer e No y in skil ep lse t ts Ou td Everyemploye’s treated the same Slo w ate dt im ec ly on tive su No on n-c No c ffe es se on all ph c te ny ibu ma istr Fax Machines Fa tig yst em es dS yst em cte fra m ne o To td ain Data Entry no dM es ate Doctor Conference Phone system Do Ou td A A ANALYZE • Metrics to measure dependent variable • Defect rate (actual counts of defect) • Number of defects per call per hour • Metrics to measure independent variables • Call traffic • Average number of coordinators per hour • Number of coordinators on duty per call A COORDINATOR EFFECTIVENESS • Out of 701 Sample calls analyzed over two weeks, the number of defects ASTRONOMICAL: 55.9 % • The correlation between the number of calls received and defects occurring: 99.9 % TREND OF DEFECT VS. NO. OF COORDINATORS A 180 160 140 120 100 Count of Call ID 80 Sum of Defect 60 40 20 0 0 2 4 6 8 10 No. of Coordinators on duty 12 14 16 TREND OF DEFECT RATES BY HOUR A 1.000 0.900 0.800 0.700 0.600 0.500 0.400 0.300 0.200 0.100 0.000 0 5 10 15 Hour of the day 0-23 Defect Rate/ Call/ Hour Defect Rate/ Call/ Hour/Coordinator 20 25 A VARIATION OF DEFECT WITH AVAILABLE COORDINATORS 1.000 0.900 0.800 0.700 0.600 0.500 0.400 0.300 0.200 0.100 0.000 0 5 10 15 20 Hours 0-23 Defect Rate/ Call/ Hour Defect Rate/ Call/ Hour/Coordinator Average of available coordinators/10 to scale 25 TIME OF DAY A 7 90% 80% 6 70% 5 60% 4 50% 3 40% 30% 2 20% 1 10% 0 0% 0 5 10 15 Average # calls per coordinator 20 Defect Rate 25 30 A ANALYZE • Correlation levels for: • Defect Rate/call/hour vs. Average number of coordinators per hour= -0.72 • Correlation between number of calls per hour and the average number of coordinators per hour= 0.865 ANALYZE A Average of available coordinators 10.000 9.000 Available Coordinators 8.000 7.000 6.000 5.000 4.000 3.000 y = -12.047x + 12.66 R² = 0.5214 2.000 1.000 0.000 0.000 0.100 0.200 0.300 0.400 0.500 0.600 0.700 0.800 Defect rate/Call/hour Average of available coordinators Linear (Average of available coordinators) 0.900 1.000 A ANALYZE • So, almost 52 percent variability can be explained by the model. • So, the regression equation line, y = -12.04x + 12.66 Example: To contain the defect rate/call/ hour at 0.1, the average number of coordinators required= 11.456 Decide between 11 and 12 coordinators! A COORDINATOR CORRELATION • We analyzed, whether number of coordinators available during a call has an effect on defect and we found a weak correlation of -28.87 percent between available coordinators and number of defect. • The negative sign re-emphasizes intuition that with the increase in number of coordinators on duty, defects will go down. A COORDINATOR EFFECTIVENESS 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Percentage Cumulative Percentage DEFECT PERCENTAGE PER OPERATOR A 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 11 12 19 23 24 25 27 28 28 28 29 30 30 31 31 33 34 37 AB CMS DNB MXK KJH TLM MAF KKH MAS AM1 EJK TCG GDC RLO MDG DAH PEC RWM WJS 38 40 43 49 SJM MES PJE Percentage Cumulative Percentage Windber Medical Center Summersville Memorial Hospital Other West Virginia Mercy Medical Center Charleston Area Medical Center UPMC Bedford Memorial Ohio Valley General Hospital Pittsburgh Home Community Hospital of Kane Punxsutawney Area Hospital Magee Women's Hospital Other Ohio East Liverpool City Hospital Wheeling Hospital United Community Hospital (Grove City) Canonsburg General Hospital V A Pittsburgh Health Care System Medical Center of Beaver Allegheny Valley Hospital Hamot Medical Center Trinity Medical Center West Washington Hospital UPMC Horizon - Greenville Campus UPMC Shadyside Hospital Indiana Hospital Altoona General Hospital UPMC St Margaret Hospital UPMC Passavant Cranberry A REFERRING FACILITY 100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% A REFERRING UNIT TYPE Pareto Chart of Defect & Source Medical Center 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% ED Tel MED ICU (blank) Percentage Labor & Delivery Other Home Cumulative Percentage MD Office Rehab Surg Percentage Cumulative Percentage TOXICOLOGY UROLOGY TRANSPLANT RADIATION ONCOLOGY PEDIATRICS ORAL SURGERY OPHTHALMOLOGY GYNECOLOGY GERIATRIC MEDICINE GASTROENTEROLOGY (blank) SURGICAL ONCOLOGY PLASTIC SURGERY OTOLARYNGOLOGY CRITICAL CARE MED VASCULAR SURGERY FAMILY MEDICINE TRAUMATIC SURGERY HEMATOLOGY/ONCOLOGY CARDIOTHORACIC ORTHOPAEDIC SURGERY PULMONARY MEDICINE EMERGENCY MEDICINE OBSTETRICS&GYNECOLOG GENERAL MEDICINE NEUROSURGERY NEUROLOGY CARDIOLOGY GENERAL SURGERY A ADMIT SERVICE 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% ADMIT SERVICE RATIO A 100% 100% 100% 88% 84% 80% 70% 67% 59% 50% 46% 59% 53% 43% 41% 38% 38% 57% 50% 53% 44% 38% 33% 29% 20% 14% 14% 0% 0% DAY OF THE WEEK A 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Wednesday Tuesday Friday Saturday Monday Sunday Thursday A BED TYPE Pareto for Bed Type 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Percentage Cumulative Percentage DEFECT RATE / BED TYPE A 0.9 0.80 0.8 0.69 0.7 0.6 0.5 0.57 0.56 0.53 0.53 0.45 0.43 0.43 0.37 0.4 0.3 0.2 0.1 0 0.25 0.24 0.40 0.20 A DEFECT BASED ON TIME OF DAY 80% 70% 60% 50% Day Shift 40% 30% 20% Night Shift VARIATION OF DEFECT WITH AVAILABLE COORDINATORS A 1.000 0.900 0.800 0.700 0.600 0.500 0.400 0.300 0.200 0.100 0.000 0 5 10 15 20 Hours 0-23 Defect Rate/ Call/ Hour Average of available coordinators/10 to scale 25 Night Time Day Time Night Time Day Time Night Time Day Time Night Time Day Time Night Time Day Time Night Time Day Time Night Time Day Time Night Time Day Time Night Time Day Time Night Time Day Time Night Time Day Time Night Time Day Time Night Time Day Time A TRENDS (10/15–10/27) Defect Rate / Time of Day 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 10/15/10 10/16/10 10/17/10 10/18/10 10/19/10 10/20/10 10/21/10 10/22/10 10/23/10 10/24/10 10/25/10 10/26/10 10/27/10 DEFECTS PER RECEIVING HOSPITAL A 60% 55% 56% 58% 50% 50% 40% 30% 20% 10% 0% Magee Passavant Presby Shadyside A TIME OF DAY DEFECT RATIO 0.8 71% 0.7 58% 0.6 0.5 45% 0.4 0.3 0.2 0.1 0 Day Time Evening Time Night Time TIME OF DAY DEFECTS A p Chart for defects/shifts p Chart for defects/shifts 0.8 p Chart for defects/shifts 1 1 1.0 0.937019 0.743287 0.8 0.8 0.6 0.707547 0.6 0.580357 p p 0.4 0.4 0.4 0.2 0.15033 0 0.223695 0.2 0 0 10 20 Sample Day 30 40 0.6 p 0.446809 0.229638 0.2 0 0 10 20 30 Sample Evening 40 0 10 20 Sample Night 30 40 DAILY DEFECTS A P-Chart for Daily Defects p Chart for defects/shifts 1 0.898197 0.8 0.6 p 0.534143 0.4 0.2 0.170089 0 0 10 20 Sample 30 40 I RECOMMENDATIONS • Night shift’s performance should be improved • Training • Performance based evaluation for their Human Capital Management Process • Reduce number of simultaneous calls handled by coordinators • Rework the phone call routing • Headset • Merge phone lines • Review process of ED transfers • Optimize the scheduling of the coordinators • Improve information infrastructure C CONTROL