Automaker’s fast-track process shows hospitals how to improve

Discharge time cut from 8 hours to 2

Patients on the eighth floor of The Cleveland Clinic Foundation (CCF) have an edge over patients elsewhere in the hospital. Once their discharge orders are signed, they are out the door in record time: less than two hours.

In an effort to continually improve its standards of care, CCF has been benchmarking with the Greater Cleveland Quality Choice Project, which unites Cleveland-area businesses and 30 hospitals to improve quality of care and service. The hospital also conducts a process-review program, PICOS, which it learned from benchmarking General Motors. (See story on one-week improvement course, p. 63.)

By focusing on the discharge process, the 1,000-bed CCF has reduced its discharge lead time from around eight hours to less than two. Lead time is calculated from the time the order is written until the patient walks out the door. As a result, CCF’s overall patient satisfaction score has jumped 40%, and its overall scores in the quality choice program have risen 9%, according to Leslie Sabo, director of service relations at CCF.

Patient satisfaction specifically with the discharge process improved 10%, according to a standard discharge process survey used by Greater Cleveland Quality Choice participants. The survey results have been confirmed by CCF’s own patient call-back program, which contacts more than 80% of discharged patients — 40,000 people each year.

Early in 1995, CCF’s patient surveys indicated that patients felt they waited too long to go home once they were discharged. CCF staff found that because so many departments were involved in getting patients ready to leave, the time it took to process paperwork was a major problem.

For instance, physicians had to provide home care instructions, diagnostic tests had to be completed, pharmacy had to make sure the patient had proper medications and instructions, social-service interventions had to be completed and follow-up appointments scheduled, and, in some cases, nutrition counseling had to be finished. But not all the departments knew in advance that a patient was ready to go home, and this slowed the process.

CCF staff benchmarked outside the health care industry to find solutions. At General Motors in Detroit, they found the PICOS technique, an intensive, five-day workshop targeted to problem identification and solution.

PICOS, Spanish for mountain peaks, is a series of workshops in which a team of hospital staff learns how to identify and eliminate waste in a problem area, then design a new process that can be implemented immediately, usually in a matter of a few months. The system, which GM teaches for free, can be used throughout the hospital, in nursing, in finance, or in administration. (See PICOS illustration, p. 64.)

CCF appointed its own PICOS discharge summary team, a 12-member group including physicians, nurses, and staff from social services, patient transport, building services, admissions, home care, and pharmacy.

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

In the first week, the team found 41 waste items in the discharge process and produced more than 150 suggestions. Forty of those were acted on immediately. They included:

• having the family stop at the cashier for a parking voucher;

• requiring residents to fill out three to four forms;

• instructing unit secretaries to wait until a patient leaves to enter the discharge into the computer.

Using patient satisfaction data and the PICOS methodology, the discharge team reduced lead time by:

• having physicians identify potential discharge patients the day or night before;

• adopting standard discharge procedures and putting discharge forms on charts to remind physicians;

• developing a discharge protocol that went into effect at the same time as the anticipated discharge order;

• hiring a discharge host, who is available by pager to assist patients into wheelchairs or provide other special needs;

• using faxes to notify all involved departments of an anticipated discharge. Department fax numbers are programmed into the machine so the unit secretary only has to dial one number for the discharge order to be faxed to each department.

The team also gave building services staff access to the hospital computer system to track discharges and identify available beds faster, decreasing admission time.

In addition to reducing discharge lead time, the changes have improved in-house productivity, says Sabo. For example, adopting a standard discharge form has cut 40% off the time physicians and residents spend on paperwork. But, she adds, the best effect has been the increase in patient satisfaction.

Building cars and rebuilding bodies have much in common, say productivity experts at General Motors (GM). Both can be broken down into a series of processes, and most processes can be streamlined to provide better service for less cost, whether your customers want a new car or treatment for pneumonia. It makes sense, then, that the same quality improvement program would work for both.

"[PICOS] looks similar to other [quality improvement] initiatives, but what makes it different is the sense of urgency. We’re looking for changes we can implement now," explains Linda Bradshaw, manager of supplier development at General Motors. "It’s exhaustive and intense. At the end, [PICOS training participants are] on a high. They made change happen."

GM has taught the system in health care facilities and health plans nationwide, including the Mayo Clinic in Rochester, MN, Memorial Sloan-Kettering Cancer Institute in New York City, and Blue Cross/Blue Shield. It has been targeting facilities that treat the bulk of GM employees, such as Detroit Medical Center and the affiliated Karmanos Cancer Institute in Detroit. At Karmanos, administrators say the workshops have stimulated a redesign that will boost productivity by as much as 30% to 50%.

"Health care organizations are looking to accelerate their improvement initiatives," explains Sabo. "Taking 12 to 18 months for data collection, reporting, then acting in these turbulent times is too long. Everyone is looking for more flexible methods."

An unlikely resource at first glance, GM actually has been teaching these workshops to the electronics and aerospace industries, as well as using it to turn around its own business.

GM’s European division developed the method in 1989 and brought it to the domestic division in 1992. The company applied PICOS internally to streamline its operations, then brought the process to its manufacturers and suppliers to further reduce costs. It also applied PICOS to its dealerships, all successfully.

That’s when GM decided to test it on its largest expense — health care. GM’s health care bill for active and retired employees adds $1,200 into the cost of every vehicle it produces. The company spends $3.5 billion a year for health care and covers 1.5 million lives, Bradshaw says.

"I’m asked a lot why we got into health care, and those figures show you why," Bradshaw says. "We’ re hoping that by improving their quality and service while reducing costs, [health care providers] will return the benefit to GM by lowering our health care costs."

[Editor’s note: For more information on the fast-track discharge process or PICOS programs at The Cleveland Clinic Foundation, contact Leslie Sabo, director of CCF’s service relations. Telephone: (216) 445-5434. For more information on using PICOS in the health care setting, contact Linda Bradshaw at General Motors. Telephone: (810) 986-6738.]