Optimization of Video-Visit Enrolment

Fishbone Diagram
HCIN-550-01-SP21 - Health Care Six Sigma
Instructor: Professor Josh Wymer
University of San Diego
Mojdeh Amini
05/04/21

© 2015 American Medical Association. All rights reserved. 1

Background
Fishbone Diagram
Cause and Effect Diagram or Ishikawa Diagram
History
• In 1960s, Kaoru Ishikawa/engineer in chemistry
• Key role in innovation and developing quality management and quality circle
• Improved the human aspects of project management
1915-1989
Advantage
Japan
• Visualizing problem and root causes
• With the relationship between the causes
Limitation
• Complex problem can result in messy or busy diagram
• A solution: Applying different colors
 How to construct the diagram?
Focusing on Causes not on Problem: y=f(x)
Cause Effect

Process

Workload

1. Problem Statement Low digital literacy

2. Categorizing of causes via

EHR downtime
Brainstorming BurnOut
3. Contributing Factors Delayed
Video Visits
4. Ask: Why?
5. More Ribs for Deeper Causes
6. Test for Root Causes Poor Connection
(Check Sheets/Scatter plots)
 Problem: “Delayed Video Visits”
Major Causes: More difficult to control or improve
• Privacy concerns and not disclosing the reason for the visit over the phone
• Electronic Health Records (EHR) documentation required multiple clicks on the tabs
• Socioeconomic issues
Minor Causes: More noticeable or easier to improve
• Poor digital and internet literacy- both providers and patients
Gaps analyzing
• Using 5Whys to get behind superficial answers
• Discussing the gaps to identify solutions
 Guide to the Project in 6 Steps
X y
Identifying a High-level Champion Input f Output
(Cause) (Effect)
Eempowering voices of the patient and Function
organization to Improve care delivery. (Process)

2 Creating an Interdisciplinary Improvement Team

3 Empowering Front-line Workers

 Guide to the Project in 6 Steps

4 Starting the Project

5 Control and Extent

Eliminating wastes
Improving efficiency
Creating value

Sustain
6
Using Worksheet to Improve Ideas
Even the smallest changes can make a difference for reducing the delays in the video visits
Submitter name(s):
Clinic: Date:
Please fill out this form if:
•You have identified waste in your workday or for patients that you want to reduce or eliminate.
•You should do workarounds because of a current process that doesn’t work well.
•You have tried to solve a problem, but it would benefit from a team approach to improvement.
•Describe the problem. If you ask “why” five times, can you identify what is causing the problem?
•Describe a potential solution to the problem.
•How will you test the potential solution?
•What will the impact be of solving the problem? Include both positive and negative effects.
•Leader review:
•□ Quick win
•□ Requires Fishbone diagram
•□ Not possible. Reason: ¬¬¬¬¬¬¬¬¬
Source: AMA. Practice transformation séries:
 Team Report
Project mission statement
What is the team trying to accomplish?
Background
• Problem background
• Why the problem needed to be fixed
• Importance of identifying solution
Original state/problem statement
• Use a diagram if possible
• Show where the problems exist with Fishbone
diagram, i.e., graphic indicators of opportunities
for improvement
• Extent of the problem (e.g., metrics or measures
of success that are below target)
Problem analysis
• Why does the problem exist?
• Does asking “why?” five times help identify the
root cause?
• What influences caused the problem?
Team
Executive sponsor:
Champion:
Team lead(s):
Project team: List names and departments
Solution
• Describe recommendations of team
• Show diagram or map of new process
• Measurable targets to achieve within determined timeframes
Implementation plan
• Use a diagram if possible
• Who is responsible for which tasks?
• What resources are required?
• What targets have been identified? Timeline for achieving?
• How regularly will the improvement team connect while the
change is underway?
Graph results
Show improvement over time
10
0
Sustain
Implementing a project doesn’t guarantee long-term success.
How does the team plan to continue to make the
improvement part of daily practice, long after the “project” as
ended? Determine metrics to track, feedback loops for staff,
and maintain regular online updates to share with the team
and supporting leadership.
Source: AMA. Practice transformation séries :
 Effect
Cause
Process Rooming
-Staff
No standard rooming
process due to MA support opening procedures and
physician preference end of day cash reconciliation
Video visit process with reception staff
variations Search for new
login
patients'
No established information
supply par levels Wasted motion searching for
Username and
patient information or
Password High turnover increases
educational material
inefficiency and training
Disorganized
No standard process for demands
login page and
patient video visit patient portals
Delayed
Video visit
Patients may not login at
Lack of enough physician and
scheduled appointment time
EHR documentation time for all
patients Patients may delete important
Cannot place lab orders for PHI during visit
new patients until they have
been established at the
Physician schedules are
practice
EHR visit documentation configured without
requires clicking to multiple Patients lack digital consideration of patient
tabs literacy or internet complexity
Physician has connection privacy concerns using video visit and
HIPAA concerns not disclosing information

MA= Medical Assistant

Documentation/EHR Patient EHR=Electronic Heath Records
PHI= Personal Health Information
Black text: causes can be controlled and improved. Red text: causes are more difficult to control and Improve HIPAA=Health Insurance
Portability and Accountability Act
Computer
Estimated Saving Time and Cost per Patient with well planed Video Visits

Source: AMA. Practice transformation series: starting lean healthcare

Ongoing Capturing Potential Wastes

Source: AMA. Practice transformation series: starting lean healthcare

 References

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https://www.ama-assn.org/practice-management/digital/most-your-patients-still-aren-t-using- portal-here-s-

why

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Kaufman, D. R., Pevzner, J., Rodriguez, M., Cimino, J. J., Ebner, S., Fields, L., ... & Starren, J. (2009). Understanding

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42(4), 581-592

© 2015 American Medical Association. All rights reserved.

 References

Gartlehner, G., Schultes, M.-T., Titscher, V., Morgan, L. C., Bobashev, G. V., Williams, P., & West, S. L. (2017). User testing of an

adaptation of fishbone diagrams to depict results of systematic reviews. BMC Medical Research Methodology, 17, 1–9.

https://doi.org/10.1186/s12874-017-0452-z

Ishikawa diagram. (n.d.). Retrieved October 3, 2018 from

https://en.wikipedia.org/wiki/Ishikawa_diagram#The_5_Ms_(used_in_manufacturing)

Pyzdek, T., & Keller, P. (2018). The Six Sigma handbook: A complete guide for green belts,

black belts, and managers at all levels (5th ed.). New York: McGraw-Hill.

Sinsky, C. (2015, June 5). Lean Health Care. Lean Health Care | Allergy and Clinical Immunology AMA STEPS Forward |

AMA Ed Hub. https://edhub.ama-assn.org/steps-forward/module/2702597.

TECOEnergyInc. (2014a, December 22). Lean Methodology: The “Analyze” Phase [Video].

YouTube. https://www.youtube.com/watch?v=YH5ig2MkBiM&feature=youtu.be

© 2015 American Medical Association. All rights reserved.

 Q&A
mamini@sandiego.edu

© 2015 American Medical Association. All rights reserved.