General Approach and Criteria
For our first cycle of project work, we propose a work plan that builds upon four identified current priorities: Compensation and Pension, Colorectal Cancer Care, Sterilizing Medical Equipment, and Care at the Bedside at our lead project facility, Boston VA Healthcare System (VABHS), and work that already has begun with our engineering partners. This will enable us to immediately jump-start NE-VERC activities in ways that contribute to key national VA issues while also focusing on our larger missions of capacity, infrastructure, and partnership building. VABHS has a strong base of clinicians increasingly involved in systems redesign and strong leadership driving improvement. Our NE-VERC VABHS Co-Director, Lynne Cannavo, will facilitate integration of our engineering partners into these teams, typically with members from multiple partners to encourage cross-fertilization and a mix of different perspectives. Culturally there is broad enthusiasm and perceived value among VABHS staff to work with our system engineers. This past spring (2009), NU senior project students participated in VABHS’s “Transforming Care at the Bedside” (TCAB) work, and after initial formalities were warmly accepted onto the team as contributing useful content and bringing fresh perspectives, with frontline staff coming to view the students as their own - several staff even attending final course presentations to support their colleagues and speak to their value-add to VA.
The NE-VERC planning process developed a set of criteria for prioritizing new projects, from which we grouped our initial work into 3 tiers:
High priority initial projects with clear applicability across the VA and identified engineering approaches,
Medium priority potential projects requiring further development to align engineering approaches, and
Smaller or less-scoped projects that may form the basis of later research seed projects, coop work when excess capacity, or pilot explorations to better scope their potential.
All projects described below currently have active improvement teams working and are excited to see their work expand to include of engineering faculty and students. More generally, the description and budgeting of these projects illustrates our “model” approach to frame and resource future projects, such as in response to Systems Redesign National Office or other priorities. To ensure capability to quickly address emerging needs, we also plan to retain some capacity in an emergent project pool, rather than fully commit our entire project budget to long-term projects that, while important, might slow our ability to rapidly address new problems. NE-VERC leadership then will be able to effectively assess, plan, skill-match, and resource such issues for greatest effectiveness.
Compensation and Pension Exams
Background and Work-to-Date: A major challenge in improving the delivery of clinical services for compensation and pension (C&P) is the steady and sizeable increase in workload. Nation-wide, the volume of benefit claims is projected to reach 872,000 in 2009, a 51% increase since 2000. VA is addressing these workload challenges by acquiring greater access to the Department of Defense online medical information. VABHS is the largest referral site for benefit exams for VISN 1 and during the first 6 months of FY 09, VABHS completed 4201 exams, of which 1017 (32%) for were patients from other VISN 1 facilities. VABHS initiated a multidisciplinary pilot program in January 2007 to improve the access and quality of benefits exams, including a work group from the Veterans Benefit Administration (VBA), C&P staff, VABHS Business Office, physicians, nurse practitioners, and physician assistants that perform C&P exams, representatives of the Director and Chief of Staff, and a System Redesign facilitator.
The team flow mapped a very complex process and identified orthopedic related exams as our initial focus, with the largest improvement opportunity. Our overall aim is to create capacity for continued growth in C&P exams by reducing processing times (current average ˜ 25 days) by 10% by July 2009, clinic cancellations with = 30 days notice, and patient cancellations and no-show rates, the latter two both by 50% within 3 months. A variety of conventional PDSA process changes tested have included: detailing a nurse to review all Orthopedic requests from the VBA prior to scheduling, making reminder calls to orthopedic patients 1-3 days before their appointments, improving C&P appointment letters to better distinguish them from regular clinical appointment letters, reducing mail out time by preventing the letter from being stuffed with additional information, and establishing a feedback mechanism on a daily basis for the section chief of the pilot group. Current data indicates that VABHS is maintaining the target turn-around-time for exams but not evidently or significantly improving towards our targets, suggesting benefits of seeking other solution approaches.
Engineering Challenges, Opportunities, and Plans: Key challenges include unpredictable cancellations by providers, significant patient cancellation rates, random and increasing appointment demand, complex documentation differing from usual clinical exams and treatment visits, and a current scheduling paradigm of interspersing visit types within a clinician’s patient load, with different characteristics, stochastics, and requirements. As one modeling approach, optimal overbooking models will be developed, used very successfully in other industries (airline, hotel, service, revenue management) but requiring adaption here to address process particulars and manage negative delay affects. The promise of stochastic, adaptive, load balancing, surge management, and sequencing (especially given heterogeneous rates) models also will be investigated, and computer simulation and predictive models will be developed to optimize resource use, demand capacity, and evaluate brainstormed policies for benefits and consequences on interdependent processes. At the undergraduate level process mapping, DMAIC, and Lean approaches will be used to help understand these interdependencies, design out waste and inefficiencies, and streamline work flow. A general focus will be on determining how to best design flexible capacity with minimal additional resource requirements, such as by pre-scheduling or adaptively shifting off-setting work during times of real or predicted low C&P demand.
In parallel, our engineering and informatics team will develop and implement applications to extract different components of electronic medical records and middleware to port information important to C&P processes into VA electronic records, especially relevant for data from external sources (e.g. DOD). Effective extraction and presentation of such information will help improve the timeliness and effectiveness of C&P evaluations. Additionally, automated support systems will be developed to guide these examinations and provide real-time feedback on patient eligibility and compliance to evaluation criteria. We also will explore and test the utility of using personal health records (PHR), such as the MyHealtheVet PHR system, to address no-shows and cancellations by tracking claimant information to empower and involve patients in their claims process. All approaches will be tested in multiple environments elsewhere within VISN 1 to assess their generalizable utility in a variety of clinical settings.
Colorectal Cancer Care
Background and Work-to-Date: A multidisciplinary VABHS team has been working to improve colorectal cancer (CRC) care performance since 2005, including GI and Surgery physicians, Systems Redesign project support, and lab, radiology, and pathology ancillary services. In 2005 national CRC improvement pilot projects started focusing on diagnosis and timeliness of colonoscopies following positive fecal occult blood tests (FOBT), co-sponsored by Systems Redesign, Office of Quality and Performance (OQP), and Health Services Research & Development (HSR&D). National spread started in FY 2007 includes a performance monitor, improvement resources site, and ongoing community of practice support, with further pilot work focused on CRC treatment and surveillance, including development of a set of quality indicators for care. Interest in cancer improvement is quite strong among clinicians, and FY 2009 saw enthusiastic response to System Redesign’s expanded role in cancer improvement and first national collaborative. Within this context, our team has 3 aims:
Design an optimal process for patients with improved reliability and timeliness,
Provide all patients with a VA appropriate colonoscopy = 60 days of positive FOBT,
Expedite workup of suspected or obvious CRC found on endoscopy.
The overall focus is to improve reliability and timeliness of care across the entire CRC care continuum. Our team currently is working on the interface between GI and Surgery clinics, with the aim that by the end of 3rd Qtr 09 100% of patients referred to surgery are informed of their GI diagnosis and have the following completed within14 days and prior to their surgical clinic appointment: a carcinoembryonic antigen (CEA) blood test, abdominal and chest computed tomography, and endoscopic ultrasound (EUS) (for rectal cancer patients). Additionally, as part of the CRC treatment and surveillance collaborative, our surgical clinic team worked on a 3 month project with Professor Steven Spear from MIT (Toyota Production expert) to use lean methods to improve our CRC care process, identifying opportunities to improve patient handoffs between GI and surgical clinics, surgical clinic scheduling (matching patients and clinicians), and patient centered communication.
Engineering Challenges, Opportunities, and Plans: NE-VERC will support the VABHS team with our modeling, informatics, and process improvement cores. Our experts in lean and process modeling will work with the team to develop reliable processes to ensure that proper actions are taken once information is generated, such as by using the reliability design approach taught by Benneyan with IHI and seeking ways to eliminate waste and identify bottlenecks during these transitions. Additional modeling effort may focus on scheduling models to match patients and clinicians, simulation and Markov flow models through the CRC process, and the dynamics of patient response to the implementation of new processes and requirements to evaluate process alternatives. Once successful, similar lean process improvement may follow in chemotherapy units to improve patient flow and chemotherapeutic agent delivery and in primary care to improve screening and surveillance.
Our MAVERIC partners have been involved with CRC quality indicator development, coordinated between OQP and the Patient Care Service (PCS) chief of Oncology, Dr. Michael Kelley, to develop informatics solutions based on natural language processing and machine learning to automatically extract and present key measures (D’Avolio, VA HSR&D, VA HIR 08-374, NCHIR, 2008). We will work with the VABHS team to determine how and when data should be displayed to clinical staff to maximize evidence-based patient care, and our modeling core will integrate their research on statistical methods to automate monitoring these indicators and evidence-base compliance (a research focus supported through NSF). Portal and document management technologies have been developed to deliver this information to clinicians and researchers via email or the web. To support the above process improvement activities, we will expand our work to retrieve critical time stamps and additional quality indicators, which also will provide an approach applicable to other cancer care processes. For example, the national SR Cancer Care Collaborative has shown strong interest in methods to track lung cancer quality indicators (treatments and critical time stamps) without requiring duplicate data entry. This work would also support current monitors for FOBT and colonoscopy timeliness and future treatment and surveillance monitors, with our statistical monitoring experts developing techniques for detecting indicator and timeliness improvements in small data sets (the norm in cancer care).
Care at the Bedside
Background and Work-to-Date: VABHS has participated in both the IHI TCAB Community and the VHA Bedside Care Collaborative for the past 1½ years. With so much care being delivered in medical/surgical units and an estimated 35-40% of all unexpected hospital deaths occurring on such units, in 2003 the Robert Wood Johnson foundation and IHI initiated a joint project, Transforming Care at the Bedside (TCAB), to create, test, and implement changes that dramatically improve medical/surgical care and improve staff satisfaction. TCAB is a foundation of the VHA FIX 09 Bedside Care Collaborative. As elsewhere, clinical staffs often are frustrated by an inability to spend more time with patients due in part to local work processes. The specific focus of VHA’s collaborative is to provide efficient and effective processes on our inpatient units via four pillars: Improvement of team collaboration, Improvement of unit efficiencies, Improvement of patient and staff satisfaction, and ongoing performance improvement. Key metrics and goals are to decrease falls to 2/1000 bed days by FY09 end, hold fall injuries (moderate and higher) to 0.1/1000 bed days, and increase nurse satisfaction by 50% (number positively reporting they work in a supportive and nurturing environment).
Six inpatient nursing units currently are participating with Northeastern engineering students and faculty on this initiative. The group conducted a workflow analysis on each unit, provided feedback on workspace design and process inefficiencies, and started working to improve the inpatient transportation process (for lab work, tests, etc). After becoming familiar with the VA, the NU undergraduates used a DMAIC six sigma approach, statistical methods, MS Access database programming, and other IE skills to develop a standardized, automated, and efficient patient transport process to increase nurse availability for bedside care. The new system has increased nurse satisfaction, reduced response times and total costs, includes real-time monitoring, is easily portable to other facilities, and has was recently presented at the May national VA TCAB conference. Other unit changes included daily nurse-physician rounding, white boards for communication, central stations installed in each pod on one unit to reduce nurse travel to check alarms, suggestion boxes for efficiency improvements, and “do not disturb” time for the patients. This is a good illustration of a “model” senior capstone project and how they will fit nicely into NE-VERC’s vision to add engineering value, respond to current VA issues, and provide cross-fertilization opportunities.
Engineering Challenges, Opportunities, and Plans: TCAB has numerous other opportunities for systems engineering to add value, particularly for student engineering projects (senior projects, coop internships) of the above type. Based on this experience, in summer 2009 NU and VABHS will initiate two additional senior projects – one focused on some aspect of the bedside care work and the other on SPD/sterilization processes (responding to recent concerns). Both projects most likely will start with basic process analysis, needs assessment, and development of possible approaches. Ultimately course requirements are that student teams fully develop, implement, evaluate, and formally present a solution, providing them valuable real world experience typically complete with unforeseen technical and social challenges, including the learned skill of identifying and selling how their skills can add value.
Undergraduate COOP and Capstone Projects
Numerous other potential capstone projects have been identified across the entire system, spanning primary care to mental health to human resources, including waste reduction and work flow improvement in admission processes, medication reconciliation issues, redesigning physical spaces, care transitions, and practice variation. Many are perfect candidates for classic undergraduate IE methods, and through this process we envision some will lead to more advanced possibilities, which then will be taken through the project development process. We envision a repeating cycle initiating 1-2 senior projects every semester, responding to immediate local and national needs and developing potential future VA full-time engineers.
Northeastern and WPI also both have substantial undergraduate cooperative education (‘coop’) programs. While many schools offer an occasional intern, in both these programs students alternate every second semester between taking courses and working full-time for a company, enriching their education with and developing capable students many of whom are hired by their employer after graduation. NU pioneered coop (together with Drexel) over 100 years ago and together with WPI have what are considered leading programs. Coop positions are another ideal way to accomplish many of our Center's objectives - exposing engineers to healthcare, building capability, developing stronger academic ties, and priming the future work-force pipeline. Unlike capstone and graduate student projects (in which students focus on just one problem and are not employed by the company per se), coop students are full time employees and tend to work on a variety of things, much like any employee. Managing coops into our processes therefore both will have broader value and larger supervision needs.
Other Potential Projects
In our process of developing and prioritizing our initial project portfolio, several other topics emerged also with strong potential for success. Our intent is to explore such topics during our normal management process and as time permits, such as if coop students have slack time in their work week, or as senior projects (those a bit more defined), and so on. In this manner, we should have a rolling portfolio of defined projects being conducted, others in the development pipeline, and capacity and structure to respond to new local or national issues as they arise.