GM helps Ohio hospital redesign care delivery

Slashes discharge process from eight hours to two

When the Cleveland Clinic Foundation (CCF) wanted to speed up its eight-hour discharge process to resolve a primary patient complaint, it sought help not from its peers in health care but from productivity experts at General Motors.

CCF staff were impressed with the Detroit-based auto maker’s proven system that teaches a team of staff how to identify and eliminate waste in any process. It stresses redesigning and implementing the process immediately.

At the end of the one-week workshop, CCF implemented a new discharge process that slashed the lag time to under two hours.

"We found problems by brainstorming," says John Dumot, DO, a gastroenterology fellow at CCF and one of the physician representatives who participated in the workshop. "There was a very intensive meeting in the beginning in which we discussed problems and possible solutions, and [that was] followed up with several other meetings throughout the year to assess programs."

Following the redesign, patient satisfaction with the discharge process jumped 10%, according to a survey used by the Greater Cleveland Quality Choice Project, a group of Cleveland-area businesses and 30 hospitals that focuses on improving quality of care and service.

Additionally, CCF’s overall patient satisfaction score has leaped 40%, and its overall scores in the quality choice program have risen 9%, says Leslie Sabo, director of service relations at CCF.

In addition, the changes have boosted in-house productivity, Sabo notes. For example, CCF adopted a standard discharge form, cutting 40% off the time physicians and residents spend on paperwork.

GM representatives have been teaching their technique, called PICOS, which means mountain peaks in Spanish, to a variety of industries. Three years ago, GM branched into health care to reduce its own payments covering medical expenses for active and retired employees.

CCF learned of PICOS from one of its board members, GM's plant manager in Parma, OH. At the time, CCF was tackling patient-satisfaction issues. In 1995, survey results showed patients complained they waited too long to go home once discharge orders were issued.

CCF knew the source of the problem — too many people involved in the discharge process. The paperwork slogged through a system that delayed the patient.

Physicians had to provide home care instructions, lab technicians had to complete diagnostic tests, pharmacists had to make sure the patient had proper medications and instructions, social service workers had to complete interventions, follow-up appointments had to be scheduled, and in some cases, nutrition counseling had to be finished. Also, not all departments knew in advance that a patient was ready to go home, creating additional delays.

With GM’s help, the hospital appointed its own PICOS discharge summary team, a 12-member group including physicians, nurses, pharmacists, and staff from social services, patient transport, building services, admissions, and home care.

41 time wasters identified

In the first week, the team uncovered 41 wasteful procedures in the discharge process including:

• requiring the family to stop at the cashier for a parking voucher;

• requiring residents to fill out three to four forms;

• requiring unit secretaries to wait until a patient left to enter the discharge into the computer.

The team then brainstormed ways to improve the process, generating 150 ideas. Forty were acted on immediately. The discharge team subsequently streamlined the process by the following methods:

• Physicians must identify potential discharge patients the day or night before.

• Standard discharge procedures were adopted, and discharge forms were put on charts to remind physicians.

• A discharge protocol was developed that goes into effect at the same time as the anticipated discharge order.

• A discharge host was hired. The host is available by pager to assist patients into wheelchairs or take care of other special needs.

• All involved departments are now notified by fax of an anticipated discharge. Fax numbers for each department are programmed into the machine so the unit secretary can dial one number for the discharge order to be faxed to all departments.

Also, building services can access the hospital computer system to track discharges and identify available beds faster, decreasing admitting time.

CCF now runs its own in-house program. Other areas where CCF has applied PICOS include preparations for same day/next day surgeries, laboratory performance time, chart retrieval, and ancillary flow.

CCF plans to conduct five to 10 PICOS workshops a year, based on topics chosen by leadership councils, according to patient and employee satisfaction and cost and quality issues.

Sabo explains that the staff likes the PICOS process because of several reasons, as listed below:

• The process is extremely targeted.

• The process is understood and supported by management.

• The process empowers staff.

• The process is outcomes driven.

• Change is accelerated.

"The terrific part of PICOS is that the methodology allows a multidisciplinary team to come together for a short amount of time and focus on one area. It is so concentrated, and there are results that can be implemented immediately," she explains.