leveraging lean tools for...2.introduction to process improvement concepts and tools 3.deploying...
TRANSCRIPT
Leveraging Lean Tools for Operational Improvements
The technical assistance for these projects were funded through the Great Lakes Practice Transformation Network. The Great Lakes Practice Transformation Network is supported by Funding Opportunity Number CMS‐1L1‐15‐003 from the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.
Today’s Presenters
Allison Bryan‐JungelsPurdue Healthcare Advisors
Laura MedowsOpen Door Health Services
Ashley WilsonOpen Door Health Services
Agenda
1. Standard work activity2. Introduction to process improvement concepts and tools3. Deploying those tools in the clinic‐ start small
• Case study on Chronic Care Management (CCM)
4. Digging in deeper‐ getting to the bottom of bigger issues• Case study on the Scheduling Process
5. Scoping projects• Case study on the Intake Process
6. Making this stick in your organization
Learning Objectives
• Identify Lean tools that can be readily used within health centers
• Understand how Lean Daily Improvement tools are used to sustain the changes made during improvement events
• Discuss the impacts of implementing the use of Lean methodologies within a health center
Standard Work Activity
• Instructions:• Get a copy of the Standard Work grid and a writing tool (you may prefer pencils)
• Listen to the verbal instructions and draw exactly what you hear on your piece of paper
• We’ll compare images at the end
If you’ve done this before, don’t tell peers what the final object should be
Introduction to Lean
• Lean healthcare is the application of “lean” concepts in healthcarefacilities to minimize waste.
• Focus on:• Respect for people• Continuous improvement
Building Blocks
Lean First Methodology
• Lean Daily Improvement (LDI)• A method for making small meaningful daily adjustments to how we work and behave in order to hold or improve a metric
• It is focused on small‐step changes and continuous improvement done by a team while they work
• Rapid Improvement Events (RIE)• Utilizes a cross functional team to address larger scale process change
• Value Stream Analysis (VSA)• A process of looking at a complete value stream to identify multiple opportunities for improvement
Sample Lean Daily Improvement
A3 for Rapid Improvement Events
Sample A3
Deploying Tools in the ClinicStart Small
About Open Door Health Services
• A FQHC located in east, central Indiana• Serves over 20,000 patients annually
• Medical• Dental• Behavioral Health
• PCMH Recognized• Member of the Indiana Primary Health Care Association HCCN (IQIN)
• EHR is athenahealth• Pop health tool is Azara DRVS
Open Door Health Services
Process Improvement Infrastructure at Open Door • Started working with PHA GLPTN in early 2017• Two teams‐ one Quality and one Process Improvement, led by Compliance and Clinical Quality Coordinator, with support from the Clinical Operations Manager• Monthly team meetings• Additional meetings scheduled as needed for projects
• Clinical Operations Manager and Clinical Quality Coordinator received training from PHA to lead Process Improvement initiatives, including LDI and RIE events
Case Study 1
Open Door enrolled in a program to assist Federally Qualified Health Centers develop a Chronic Care Management program and successfully bill the CCM code.
Stage 1 – Identify Problem to Solve
• Identify Problem & Current Process Steps• Limited identification/enrollment of CCM eligible patients; currently identified through verbal referrals
• Establish Process Metrics, Baselines and Goals• Leading Metric – Identify 4 CCM eligible pts/day• Lagging Metric – Enroll 30 CCM eligible pts/month
• Identify Team Members
Stage 1 – Identify Problem to Solve
Stage 2 – Define & Document Standard Work/Training
• Establish Standard Work and initiate training ‐Azara DVRS report
• Establish tracking method‐Documented in patient record
Stage 2 – Define & Document Standard Work/Training
Stage 3 – Data Collection, Visuals & Team Huddles
• Determine data collection methods• Tracking through EMR/Azara DRVS daily report
• Create and install visual management board• Run chart• Countermeasure form• Pareto Chart• Attendance
• Establish/Start team huddles• Who? When? Where?
Stage 3 – Data Collection, Visuals & Team Huddles
Stage 4/Stage 5 – Hardwiring & Sustainability
• Hardwire the process, utilizing Pareto and countermeasures to address barriers• Close LDI after 30 days of meeting/exceeding Leading metric goals•Monitor Lagging metric goals at close to determine impact
Digging in Deeper Getting to the bottom of bigger issues
Understanding the 5 Why’s
• Simple concept‐ ask WHY 5 times• Finding the root cause to fix the right issue• Focus on process, not people
Addressing Bigger Issues
• Bigger issues need different tools• Rapid improvement events
• 3‐4 days• Cross‐functional team• Lots of Post‐It notes• Identify current state• Design future state• Test
Case Study 2
Improve Patient Scheduling• Primary focus was on throughput
• Scheduling, Registration, Intake
RIE Steps
• Identify problem/s or a process to improve• List process steps and who is involved at every step (SIPOC)• Identify metrics to measure and compare• Create team• 3‐4 day event
• Gemba walk• List and group problems identified during walk• Root Cause Analysis‐5 why’s• Team creates balanced solutions• Implement changes needed to support solutions• Create and role out new process
SIPOC FlowSuppliers provide the
Inputs needed to complete the
Process steps that result in
Outcomes that are used by the
Customers
Scheduling RIE‐ Challenge Statement
The current scheduling process varies between providers and appointment types.
This creates confusion on why the patient is being seen and a lack of available appointments.
This RIE will focus on delivering a standardized scheduling process which will result in increased patient satisfaction, increased patient access and more efficient internal processes.
RIE Steps
Process Start:Patient needs appointment
Process End:Medical Records and Translation Service Triggered
Included: Primary CareExcluded: Urgent Care, Family Planning, Pediatrics, Behavioral Health
The Team
Process OwnerSchedulerMedical RecordsMed AssistantPSRExecutive CoordinatorProviderTriage NurseTeam NurseAlternate (SME)CQC
Meaningful Metrics
Goal was to create standard work for scheduling team• Average time to answer call• Average call time • No show rate %
• Make sure your metrics will have a direct impact on reaching your desired outcome or future state
• Ensure the metric can be easily tracked and reported on• Spend some time in the front end doing validation of the data and creating the report that will be used
Identifying the Gaps
• Gemba Walk• Observed the process and identified gaps and bottlenecks
• Affinity diagram• Team grouped similar issues, gaps and bottlenecks together
Root Cause Analysis
Implementing Balanced Solutions
Description Balanced Solution
Hypothesis Metric Expected Impact
Observed Impact
Next Step
Create draft standard work
Create script for education
Increase consistency in education delivery
Ave call time, Patient Survey, Ave time to answer
Increase consistency in education delivery
Drafted & to be included in new process
Completion Plan
Completion Plan
• Any open items that were not finalized during the RIE went on our completion plan• Action item• Person responsible• Due Date• Status
Next Steps
Lean Daily Improvement• Daily tracking of metrics • Daily RIE team huddles• Visual Management Boards
Outcomes‐ Scheduling Metrics
Metric Pre-RIE Post-RIE TargetAverage Handle Time
1:55 1:30/1:45 1:30/1:45
Average Time to Answer
1:05 30sec <70sec
Additional Elements
• Parking Lot• Used when items needed additional follow up but may have fallen outside of the scope of the RIE
• Established Process Owner• The individual responsible for ensuring that the new work sticks• Responsible for tracking the measures and reporting out to the team
• Daily Report Out to Leadership• Executive Sponsor‐CFOO• Additional leadership‐CMO, Compliance, CEO, Community Awareness, Upper and Mid level Management
Scoping ProjectsUsing the Right Tool at the Right Time
Which Tool to Use When
• Lean Daily Improvement• A small scoped problem usually focused in a particular area. This problem can be addressed by the team members involved as they establish the initial details of the work and then continue with daily problem solving.
• Rapid Improvement Event• A larger problem that touches multiple teams/areas of the facility. The current state from every perspective needs to be identified before the future state can be established.
• LDI can be used to implement the new standard work as it pertains to each team/area.
Picking Metrics
• Leading metrics‐ near term metrics you can monitor in real time• Diabetic measures blood sugar numbers daily
• Lagging metrics‐ metrics with impacts that will occur later• Diabetic A1c in good control
• Data available• How will you track/capture?
Case Study 3
Improving the Intake Process to Improve Quality Measures•Multiple LDI/ PDSA projects
• Sometimes effective• Many times teams operated in silos and not moving in the same direction
• Common denominator was that many quality initiatives were driven and captured during patient intake
RIE #3‐ Intake Process
• Followed same process for RIE•Metrics included:
• Intake Time• Completed Documentation (quality measures were included in this)• Blood Pressure screening complete
RIE #3‐ Intake Process
Current StateGaps Identified Balanced Solutions
Outcomes‐ MA Intake Metrics
Metric Pre-RIE Post-RIE Target
Med Rec 49% 91% 90%
BP every visit 85% 100% 95%
Intake time 14:48 <10 10
Lessons Learned
• Importance of leadership support• Comprehensive systems approach
• Include the right people in Quality and Process Improvement Initiatives• Creating a culture conducive to change
• Change Management• On‐boarding
• Staff education and training• Organizational structure
• Avoid operating in silos, create a structure for Performance Improvement that facilitates a natural communication flow and chain of command
New Infrastructure
• Re‐organization of Quality and Performance Improvement Unit• 3 tiered approach
• Clinical Ops• Informatics‐ missing piece• Compliance
• One team, all moving in the same direction• Provider representation• Management • Clinical staff• Additional roles included as needed
Making Change Stick
Sustaining Change
• Leadership buy‐in• Leadership engagement• Empowering staff to suggest change• Visual management boards of projects in progress• Periodic review of consistent metrics• Establish as part of the QI culture
• Include in staff on‐boarding• Celebrate success
In Summary
•Many tools exist to support continuous change within the clinic• Focusing on a core set of tools makes it easier for staff to adopt change• Use the right tool for the right problem• Choose metrics carefully• Celebrate wins!
Questions?
Contact:Allison Bryan‐Jungels (Purdue) [email protected] Medows (Open Door) [email protected] Ashley Wilson (Open Door) [email protected]