Running head: DURABLE MEDICAL EQUIPMENT 1

Durable Medical Equipment Process Improvement Proposal

Latoya Rone and Aaron Yee

University of San Diego

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Abstract

The current baseline of timely issuance of Durable Medical Equipment (DME) to patients

at a prison facility located in southern California is far below the institution’s target goal of 95%.

The current process is prone to errors, wasted resources, and unnecessary staff rework. By using

Lean Six Sigma methodologies, this process improvement proposal aims to streamline the

workflow, eliminate out of compliance DME issuance, free up wasted resources, and make the

institution compliant with patient safety standards, Americans With Disability (ADA) laws, and

policy directives. The goal of this proposal is to provide this facility with high-level workflow

improvement recommendations to aid in meeting their 95% DME compliance target.

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Durable Medical Equipment Process Improvement Proposal

Introduction

Durable medical equipment (DME) is any equipment that offers therapeutic benefits to a

patient in need due to a particular medical condition and consists of items that are primarily:

ordered by a physician, used to serve a medical purpose, and are reusable (BlueCross, 2018). In

healthcare, DME is typically prescribed by a physician for a patient to safely and appropriately

use in their home. Unfortunately, many patients in the United States face institutional barriers to

DME access. Although universal access to healthcare for incarcerated persons is mandated by

the Eighth Amendment of the U.S. Constitution, many prison inmates are subjected to delayed

assessment of DME necessity, prescribing, and procurement due to constraints of the prison

system and its typically limited resources (Shalit & Lewin, 2004). A prison facility located in

southern California is facing potential negative patient outcomes due to delayed DME issuance

as a result of a poorly designed workflow process. The facility has no effective tracking process

to ensure each individual inmate has necessary DME in their possession and many inmates have

not been issued critical DME such as wheelchairs, walkers, braces, monitors, and protective

vests.

This high-level process improvement proposal aims to reduce wasted resources,

unnecessary staff rework, delays in treatment, and negative patient health outcomes at this

correctional facility by using Lean Six Sigma methodologies to streamline the DME distribution

and tracking process. Analysis of the current DME workflow will reveal nonvalue added (NVA)

and value added (VA) steps and identify gaps and inefficiencies in the process. This information

will be applied to the process improvement proposal, presented in the form of a future state
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workflow with projected benefits. The objective of the proposal is to aid this facility in meeting

its 95% DME compliance goal and reduce negative DME-related patient outcomes.

Problem

Timely issuance of DME was identified as a problem at this institution through the high

volume of healthcare grievances and healthcare requests for services submitted by patients.

Within this correctional facility, effective coordination between care teams and patients is

required to dispense DME within required timeframes. Unfortunately, the current work flow for

DME procurement, distribution, and tracking is disjointed resulting in noncompliance in issuing

DME. Without a streamlined approach, the current process is prone to errors and negative patient

outcomes. Not only is timely issuance of DME imperative to ensuring patient safety, but it is also

a legal mandate (Centers for Medicare & Medicaid Services, 2017).

Outdated electronic health records (EHR) systems, policies, and lack of human resources

result in communication breakdown which ultimately compromises patient safety. Inmates with

debilitating medical conditions are not receiving critical DME in a timely manner or are issued

incorrect DME altogether due to mistakes made during the ordering process. When ordering

DME, physicians are placing orders under incorrect categories or inappropriate levels of need.

Clinical and procurement staff are often unable to provide requested DME in the requested time

frame due to unclear DME descriptions or lack of availability, resulting in non-compliance. The

current distribution process at this facility includes a flawed receipt-based system, which further

delays delivery of DME. While the receipt process is intended to serve as a supplementary

tracking system to the EHR, it has instead created inaccurate noncompliance data as correctly

issued DME are not always reflected in these receipts. These errors in turn result in staff rework

and wasted resources as staff are consistently working to absolve these DME-related issues.
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Historical data at this facility showed a baseline of performance far below their goal of 95% for

DME compliance, demonstrating a need for process improvement.

Literature Review

Romanoski and Swope (2018) described that for individuals with a disability, DME can

substantially improve overall quality of life by increasing a person’s independence with

functional mobility and activities of daily living (ADLs). Durable medical equipment greatly

helps patients live healthier lives and it can therefore be considered insufficient treatment if

DME is not appropriately incorporated in patient treatment plans (Antod, 2012). By determining

appropriate equipment needs, individuals who were once dependent on others may regain

independence in hopes of returning to their prior level of function and enhance their

psychological wellbeing and social engagement (Romanoski & Swope, 2018).

Studies have also shown that new medical devices are getting to patients too slowly,

delaying treatment and leading to adverse events (Blanding, 2015). This can be attributed to

lengthy delays to the medical device approval process as well as clinicians’ attitudes toward

medical devices in healthcare delivery. According to a systematic review by Zhang, Bariball, and

While (2014), clinicians associated the use of medical devices with increased personal stress,

decreased autonomy, and increased administrative time. Because DMEs improve safety and

decrease the need for caregiver assistance, clinicians should not only issue DME in a timely

manner, but also understand the importance of DME in contributing to better patient outcomes.

Medical equipment is intended to aid in the monitoring, diagnosis, and treatment of

health conditions. The accessibility and maximum use of medical equipment is essential in

improving the quality of health services. Problems with the timely issue of medical equipment
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and materials disrupt care and waste the health specialists’ workdays. Besides, the patients and

family members feel disappointed because of poor services.

Many health centers do not give attention to ensure there is a timely supply of all types of

medical equipment that meet the needs of all patients. As a result, clinicians have no option but

to leave the patients bedsides and unattended to look for equipment or materials delaying care.

The unattended patient in many cases feels devastated because the health specialists who are

supposed to help are paying little or no attention (Guédon et al., 2016). The privileged families

may be able to purchase or hire the necessary resources, but the unprivileged are left unattended,

which may lead to their death. This is common especially to patients who do not have or cannot

afford to pay for insurance coverage.

Moreover, delayed or unavailability of the medical equipment is known to cause stress

and delays in the operating room, which can elicit extra risks to patients (Moyimane, Matlala, &

Kekan, 2017). Stress reduces the level of human performance, which increases the probability of

errors in the operating room. Besides, delays in the operating room can worsen the condition of

the patient or cause death. Therefore, hospitals should ensure there is a timely supply of medical

equipment to avoid delays and stress among clinicians and patients. Timely supply will increase

efficiency and reduce the high number of deaths.

Goals, Objectives, and Purpose

This proposal aims to improve patient care by eliminating out of compliance DME

issuance and free up wasted resources that result from the current DME process. In Lean

methodology, inefficiencies are called “waste” (Qualis Health, 2011). In this proposal, workflow

analysis and process mapping will be used to analyze the system of steps, expose waste, and

guide a more efficient design. A value stream map will be provided identify which parts of the
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workflow are causing the most waste and inform how the future state process map should look.

Streamlining the process should directly result in improved timely issuance of DME and

compliance rates. DME includes but is not limited to improve the timely issuance of following

items: wheelchairs, wheelchair cushions, walkers, C PAP machines, pillows wedges, reading and

sunglasses. A more efficient design should reduce confusion for all teams involved in the process

and provide easier tracking of DME. By eliminating NVA steps, which only cause unnecessary

workflow complications, staff should better be able to track DME once ordered for an inmate.

The goal for this process improvement proposal if implemented is that the institution will

achieve its target DME compliance of 95% across all DME categories (Same-Day, 5-Day, 14-

Day, and 90-Day DME orders).

Additionally, this process proposal should result in improved patient outcomes. By

increasing the efficiency and speed in which the inmates receive critical DME, the institution

should see a decrease in exacerbations of medical conditions related to lack of equipment

(Romanoski & Swope, 2018). As described, the inmates have reported several grievances and

requests for care related to lacking DME equipment. This process improvement will ensure that

these inmates receive appropriate DME in order to receive therapeutic benefit and to prevent

further associated complications. Patients with debilitating conditions should no longer wait for

extended periods to receive their DME due to inadequate organizational processes. A decrease in

these healthcare grievances reported by inmates should therefore follow process improvement

implementation.

Scope of Work, Plan of Action, Activities

The scope of this proposal will only include DME orders placed by the physicians in the

institution. Orders for medications, therapy, and other treatments will not be addressed as they
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follow different workflow processes. Durable medical equipment supplies (wheelchair gloves,

seat cushions), accessories (distilled water for C-Pap/Bi-Pap machines, test strips for

glucometers) and other materials (bandages, incontinence supplies), will also be excluded from

this proposal since these supplies are available onsite and do not require the same acquisition

process as DME.

This project will initiate with the workflow analysis of the DME process. The Chief

Support Executive (CSE) will function as a liaison to the project and help identify process steps,

length of each step, and which departments are responsible. The institution’s EHR will also be

used to analyze documentation and research the flow of the DME ordering process.

To focus the project, a defect analysis must first be conducted to identify what type of

DME errors are occurring most frequently. Once this is established, the proposal will be focused

on targeting these specific sections of the workflow. With information provided from the CSE,

an initial work flow process map will be developed. Once the process has been mapped out,

additional research will be conducted to create a VA vs. NVA steps table to analyze the current

DME process. This additional research will include interviewing the CSE, analyzing DME

documentation within the EHR, and performing audits on the many data points provided by the

institution. The VA vs. NVA table will function as a gap analysis to aid in pinpointing which

steps are causing the most delays and restraints. These wastes will be then revised to create the

future state process map, which will encompass this project’s process improvement proposal.

Work Breakdown Structure

The hope for this project is that it will ultimately involve many departments within the

institution as their input is required to confirm effectiveness of the proposed solution and

implement if so desired. For the purposes of the proposal itself, the developing team is
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comprised of healthcare informaticists (see Figure 1). Working closely with the CSE, these

informaticists are tasked with utilizing the EHR to collect data entered by clinical staff and audit

the information to find waste. These NVA steps are to be reported to and confirmed with the

CSE throughout the research process and prior to creation of the current state process and value

stream maps.

Figure 1. RJD work breakdown structure.

The completed process improvement proposal, including the future state process map,

will be submitted to the CSE. Should the proposal be reported to and approved by the executive

sponsor as an effective and valid DME workflow, the proposal may be implemented for the

institution. A project manager would be needed to implement the new process for the

organization to delegate change tasks and training as necessary to the appropriate departments. If

successful, this new process has the potential to be applied to associated facilities statewide.

Deliverables

In order to perform a structured workflow analysis, each individual step within the initial

process was categorized into the VA vs. NVA table (see Figure 2). By separating the VA-only
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steps, this table eliminated all remaining workflow waste and staff re-work loops and identified

which steps would be included in the final future process map (see Figure 3).
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Non-Value Added (NVA) Value Added (VA)

ₓDetermine medical need for DME ₒPatient assessment
ₓCreate DME order details ₒOrder DME in EHR
ₓDetermine if DME is Nonformulary
PCP
ₓCP&S for approval
ₓCME OT emails decision to distribution list
ₓInform patient during follow-up
ₓReview order in EHR during discharge ₒIssue ordered DME to patient
ₓDetermine if DME is in stock in clinic
ₓInitiate patient follow up appointment in EHR
ₓOrder DME receipt in EHR
NURSE ₓPrint out DME receipt
ₓHave patient sign DME receipt
ₓCopy signed DME receipt
ₓGive patient DME receipt
ₓRoute DME receipt to Health Information Management
ₓReview order from EHR requisition ₒOrder DME
ₓReview order to determine if DME in stock
ₓBegin procurement process
ₓReview order for completion
ₓE-mail PCP for clarification
ₓReturns to requestor for additional information
ₓDeliver to requestor on predetermined delivery day
ₓLog items to order on spreadhseet
ₓIf urgent order, urgent DME request
ₓReview distribution e-mails for RPS approval
ₓDetermine if priority request form is completed
ₓExemption request required for PIA items
ₓPriority request routed to CEO for review
ₓPriority request routed to vendor for quote
CENTRAL
ₓReview quotes
SUPPLY
ₓCreate urgent purchase requisition
ₓEnter urgent purchase requisition
ₓScan documents into shared folder
ₓE-mail requisition to local budget analyst
ₓHealth program manager reviews requisition
ₓHealth program manager releases requisition in EHR
ₓHealth program manager informs budget analyst
ₓSend requisition packet to fiscal for approval
ₓBudget analyst forwards to acquisition management services
ₓFollow up with vender to reorder DME
ₓFollow up with vendor to confirm delivery date
ₓFollow up with warehouse for delivery status
ₓReceive DME from warehouse
ₓPerform goods receipt
ₓReceive intake request vie e-mail ₒCreate purchase order
ₓReview request for completion
ₓReturn to requestor for additional information
ₓInput request into tracking log
ₓCreate physical file of request and supporting documents
ₓManagement reviews file for accuracy
HQ
ₓAssign to analyst for completion review
Procurement
ₓDetermine acquisition method
ₓConfirm/obtain price quote
ₓAward order to vendor
ₓReturn file to intake
ₓIntake e-mails purchase order to requestor and vendor
ₓVendor confirms purchase order receipt via e-mail
ₓReceive completed 7635 copy
Health Care ₓReview 7635 for appropriate documentation
Compliance ₓDetermine if 7635 is complete
Analyst ₓEnter on DME Log
ₓRoute various departments paper 7536
ₓAccept DME ₒReceive DME
Patient ₓSign 7536
ₓTake copy of 7536

Figure 2. VA vs. NVA Steps Table

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Figure 3. Future Process Map

Conclusion/Next Steps

Next steps, possible outcomes and future opportunities involve numerous meetings with

the Chief Support Executive (CSE) and her team to discuss: potential financial benefits for

the organization, feasibility of the proposal, and implementation strategies. Potential

financial benefits are best supported annual soft savings which displays staff rework by cost

per defects; defects total to the amount of project savings $1,326,239.14 (see Figure 4).
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Moreover, project savings will contribute to feasibility of the proposal along with working

with stakeholders in headquarters. Implementation strategies will include the removal of the

7536, implemented in process map above, and optimization of the EHR; which will capture

all data in one area. Following steps will be to proceed working with multi departments to

change business practices to improve patient outcome.

Annual soft savings:

Cost avoidance:
no. of defects
name of cost item eliminated per annual
incurred by defects year cost per defect savings
Staff rework 7362s 364 288.55 105032
Staff rework 602s 342 747.78 255741
Staff rework 1824s 286 964.77 275924 ,
Staff rework form 22s 416 197.06 81977
Elimination of work:
hours of work average hourly
eliminated per no. of items fully-burdened
each item processed labor cost for annual labor
name of task that was removed processed each year PY savings
Rework by nurse 1.00 4111 39.42 $162,056
Rework by physcian 0.50 4111 149.26 $306,804
Rework by materials and stores
supervisor 1.00 4111 33.74 $138,705
TOTAL PROJECT SAVINGS: $1,326,239.14
(Figure 4)
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References

Antod, J. (2012). Why every chiropractor should be a DME (durable medical equipment)

supplier. The American Chiropractor. Retrieved from

http://theamericanchiropractor.com/why-every-chiropractor-should-be-a-dme-durable-

medical-equipment-supplier/

Blanding, M. (2015). New medical devices get to patients too slowly. Forbes HBS Working

Knowledge. Retrieved from

https://www.forbes.com/sites/hbsworkingknowledge/2015/08/11/new-medical-devices-

get-to-patients-too-slowly/

BlueCross. (2018). Durable medical equipment. Retrieved from

https://www.bluecrossnc.com/sites/default/files/document/attachment/services/public/pdf

s/medicalpolicy/durable_medical_equipment_%28dme%29.pdf

Centers for Medicare & Medicaid Services. (2017). Durable Medical Equipment (DME) Center.

Retrieved from https://www.cms.gov/center/provider-type/durable-medical-equipment-

dme-center.html

Guédon, A. C., Wauben, L. S., van der Eijk, A. C., Vernooij, A. S., Meeuwsen, F. C., van der

Elst, M., & van den Dobbelsteen, J. J. (2016). Where are my instruments? Hazards in

delivery of surgical instruments. Surgical Endoscopy, 30, 2728-2735.

Moyimane, M. B., Matlala, S. F., & Kekan, M. P. (2017). Experiences of nurses on the critical

shortage of medical equipment at a rural district hospital in South Africa: a qualitative

study. Pan African Medical Journal, 28(100). 1-8. doi:10.11604/pamj.2017.28.100.11641

Romanoski, N. L., & Swope, K. (2018, Sept.). Durable medical equipment that supports

activities of daily living, transfers and ambulation. PM&R KnowledgeNow. Retrieved

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from https://now.aapmr.org/durable-medical-equipment-that-supports-activities-of-daily-

living-transfers-and-ambulation/

Qualis Health. (2011). Workflow Analysis. Retrieved from http://medicare.qualishealth.org/qi-

basics/workflow-analysis

Shalit, M., & Lewin, M. R. (2004). Medical care of prisoners in the USA. Medicine, Crime, and

Punishment, 364, 34-35. doi:10.1016/S0140-6736(04)17633-2

Zhang, W., Barriball, K. L., & While, A. E. (2014). Nurses’ attitudes towards medical devices in

healthcare deliver: A systematic review. Journal of Clinical Nursing, 23, 2725–2739.

doi:10.1111/jocn.12601
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HCI Program Competencies

The Health Science Knowledge and Skills Outcome reflects the human-computer

interaction (HCI) program competencies by developing an understanding the of the nation’s

health care delivery system, models of care, health care provider roles, and impact on

populations that access them. The HCI will establish and sustain feasible operations and improve

accessibility on from provider’s end.

Leadership and Systems Management Outcome incorporate HCI program competencies

through the strategic planning completion process of streamline auditing of Durable Medical

Equipment (DME). Outcome strengthens decision-making strategies and prioritization.

Moreover, competencies will address ethical leadership principles to solving complex human

error systems issues.

Systems Design and Management Outcome reflects HCI program competencies with the

deliverance of a current and future state process map to reach a DME timely issuance of 95%.

Process map aims to improve DME tracking process and documentation utilizing while reducing

delays in treatment and negative patient health outcomes.

Data and Knowledge Management Outcome reflects HCI program competencies of this

project by the integration of systems and technologies into the long-term information

management needs and plans of the prison. In addition, Microsoft Office and Powerchart will

assist to analyze patient records in project.

Quality and Regulatory Outcome reflects HCI program competencies of this project by

improving policy and privacy through management of electronic health services. In an effective

streamline process, good regulatory outcomes should measure patient quality to prevent medical

error from occurring.

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Social Justice - to demonstrate and promote diversity and equality effectively to improve

the opportunity to sustain community flourish and social well-being. Social justice reflects HCI

program competencies of this project by creating a system that delivers timely issuance of DME.

A system that contributes to improve equality for all inmates, reassuring them that their medical

needs will be met within an appropriate time frame.