A 1-week course on fast improvement
PICOS is a fast-track improvement process taught by Detroit-based General Motors (GM) in a one-week workshop. The following are its essential components:
• Identify the problem.
Almost any process can be tackled in the workshop. The Cleveland Clinic Foundation used it to analyze its discharge process, preparations for same day/next day surgeries, laboratory performance time, chart retrieval, and ancillary flow. The Karmanos Cancer Institute in Detroit used PICOS to restructure its organization, breaking up traditional departments and grouping people who treat the same patients. GM’s system also helped Karmanos create a single computerized patient record to replace a cumbersome process of pushing papers through departments.
• Assemble the team.
The team should be composed of eight to 10 people who represent all those involved in the functions of the process. "These are the key players," says Linda Bradshaw, manager of supplier development at GM. "They can be physicians, the nurses, the secretaries. Everyone who will have a direct impact on the process."
• Analyze lead time.
The team walks through the process, looking for waste. Here are the seven waste areas GM defines, along with examples of each:
correction: inspection reports;
motion: poor department layout;
material and information movement: excessive handoffs;
inventory: documents, forms;
overproduction: excessive work in process between functions;
processing: microfilming;
waiting: long process time.
The team identifies every step in the process, establishes the time required for each step, and defines each step as value- or non-value-added.
"We really go through it step by step," Bradshaw says. "We look at the process and what’s happening to the patient. For many people, this is the first time they’re looking at it from the patient’s point of view, and they are surprised at what they put the patients through."
• Brainstorm solutions.
The team returns to its meeting room and scrutinizes the process it just charted, looking for ways to cut waste by reducing, eliminating, or combining steps. Key discussion areas are employee tasks, workplace organization, visual control, and facility and office layout.
"They’ll wallpaper the room mapping out the process," Bradshaw says."A lot of things surface, like realizing how much time they spend running up and down hallways looking for equipment."
• Analyze and select solutions.
Sift through the brainstorming papers and pick out the solutions that can be implemented. "They’ll have 150 ideas," Bradshaw says. "Now you need to bring them back down to earth and identify the actionable items things they can do immediately."
• Redesign the process.
Discuss the plan with stakeholders. Implement the plan immediately, focusing on what can be done in that week. Apply zero- and low-cost ideas first. "This isn’t a typical path to redesigning a process," Bradshaw says. "They don’t wait weeks or months for someone to approve it. The key people have already said, You find what you want to do and do it.’"
• Verify and adjust.
Tweak the process as needed. Establish a system to measure improvements. The team also must follow up to ensure the plan is implemented. "It’s not a one-week process," Bradshaw says. "We hope that once we leave, they’ll continue doing this on a regular basis. We’ll help support them and come back, but eventually they should be running their own workshops and continuously trying to improve processes."
[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 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.]
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