Using Lean/6 Sigma Methodology to Facilitate Medical Home Implementation

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1 Using Lean/6 Sigma Methodology to Facilitate Medical Home Implementation Timothy Quinn, MD, MBA President, MercyCare Community Physicians

2 The MercyCare System MercyCare Community Physicians is a physician-led system of 21 clinics and 76 health care providers. 13 primary care locations in Cedar Rapids and the surrounding communities, such as Mount Vernon and Monticello 3 urgent care locations 4 specialty locations: Internal Medicine, Endocrinology, Occupational Health and Pulmonology & Intensive Care First of its kind Employee Health Center for Mercy and MercyCare employees and their families Affiliated with Mercy Medical Center in Cedar Rapids, Iowa

3 Changes in Health Care Using Lean/6 Sigma Methodology to Implement Changes Throughout MercyCare System. Patient Centered Medical Home Emphasizes a team approach focusing on measurable quality, rather than quantity. Certification relies on meeting several criteria: extended access, care management, follow-up, performance reporting, electronic prescribing, etc. Emphasizes using Electronic Health Records (EHR) to improve the quality of health care. E-prescribing, improving coordination through electronic exchange, quality reporting, engaging patients and providing privacy and security are all requirements to incentivize providers. Meaningful Use Accountable Care Organizations Emphasizes coordination as a way to improve the quality of health care. Groups of health care providers form ACOs to better coordinate their efforts, the model ties reimbursement to quality metrics and cost reduction.

4 National Committee on Quality Assurance Top Quality Care 94% 90% 88% 93% 90% 90% 82% 41% 50% 42% 71% 69% 51% 63% 58% BMI Mammogram Colorectal screening HBA1C Screening MercyCare Commercial HMO Insurance Medicare HMO Insurance Medicaid HMO Insurance MercyCare consistently outperforms national averages for proactive screenings, preventive care and management of chronic conditions, such as diabetes leading to lower costs and higher patient quality of life.

5 Benefits of Lean Provides a structured process to begin implementing change. Organizes projects to ensure compliance with health care reform. Focuses on change as a team effort. Develops easy to follow processes to solve problems. Makes standardization throughout a system easier. Eliminates waste to reduce costs. Controls the process after implementation to track success. Improves the quality of care we provide.

6 Lean/6 Sigma Principles MercyCare s continuous improvement efforts are to create value for the customer which is done by eliminating waste. Eliminating waste is the key to improving quality, cost and delivery. Continuous Improvement IS: A way to use employee s knowledge and experience to improve results A way to organize improvement activities in a methodical way An ongoing set of continuous improvement solutions not a single fix it all today event. Continuous Improvement IS NOT: A method to get everyone to do more or faster work A job elimination exercise

7 Waste Elimination 8 Types of Waste we strive to eliminate: Overproduction, correction (defects), inventory, motion, over processing tasks, conveyance, waiting and under use of human intellect. 5S Process Removes Waste & Improves Safety Waste Sustain Assign responsibility and audit for compliance Sort Eliminate infrequently used items Safety Waste Set in Order Organize and label a place for everything Waste Standardize Build consensus and communicate procedures Shine Clean it Waste Waste

8 Lean/6 Sigma at MercyCare A methodology of problem solving based on fact based discovery A cultural attribute that drives competitive advantage 6s A never ending journey of continuous improvement by fully satisfying patient requirements A statistical measure of the ability of a process to meet customer requirements Data Driven Team Problem Solving

9 5 Step Problem Solving Process 5 CONTROL: Maintain Gains Future Improvements Lessons Learned 4 IMPROVE: Implement Solutions Evaluate Results DEFINE: Purpose/Scope Problem statement Impact Assessment 1 PROCESS 2 MEASURE: Focus Improvement Define Current Situation 3 ANALYZE: Root Cause Analysis This Process Improvement Model Provides: A framework for improvement A common language A checklist so we don t miss a key step A documented process so we can improve it-we need to improve how we improve

10 Sigma Level Quality Defined Baggage claim operates at 4 Sigma: one lost bag for every 160 handled. 4 6, , , , , , , , , , , ,000 Defects per Million

11 Quality Defined Quality means a high degree of excellence, this is achieved through low variation in processes. At MercyCare quality means: Consistently meeting customer requirements at a competitive cost Consistency did we deliver the service in a timely manner? Customer Satisfaction did we deliver the right service? Competitive Cost did we deliver the service at the right price? 99 % Quality means 6s Quality means 5,000 incorrect surgical operations/week 200,000 wrong prescriptions/year 2 short or long landings at major airports/day. 20,000 lost articles of mail/hour For Our Customers 99% Quality Is Simply Not Good Enough 1.7 incorrect surgical operations/week 68 wrong prescriptions/year 1 short landing at major airports every five years. 7 lost articles of mail/hour A Six Sigma Process delivers % Quality

12 Measuring Performance Why is it important to measure process performance? It is important to measure process performance to know where your process is performing compared to the organizational or customer requirements. By monitoring your processes you will quickly be able to identify any changes in that process and to implement an action plan to address changes that are negatively impacting your process performance. How do we measure? Scorecards are a common performance measurement tool that we use so we can visually see how our processes are doing compared to goals or customer expectation. Merit based pay tracking to identify how we perform against our individual goals. Establish Key Goals Establish Metrics Understand Performance Initiate Improvement

13 Lean/6 Sigma Project for Medical Home Implementation Define Problem: Accountable Care Organization formation and Patient- Centered Medical Home certification are necessary components of health care reform. These models include a combination of access, team work and technology to deliver quality care and improve health. Currently it is unknown what Medical Home level each MercyCare clinic would qualify for if they applied for certification. Goal: 13 Medical Care clinics certified at any Medical Home level in Scope: Medical Home Certification Deliverables: Improve care coordination and continuity of care leading to cost reduction and Medical Home certification. Analyze Utilize the certification tool provided by the NCQA to identify the Medical Home level at which each clinic is currently performing. Tool provides certification level scoring, with these scores we will be able to identify the requirements that need to be met for each level of certification. Measure Current state: no MercyCare clinics are certified Medical Homes Identify the 30 criteria which must be met for medical home certification-complete Identify VOC (voice of customer) and Mercy requirements Physician Staff Patient Identify gaps in the current process Of the 30 criteria, which do not currently have processes defined Improve/Control Long Term Actions: Goal: to achieve level 3 certification at each clinic. Implementation plan: Identify the criteria met for each clinic Identify the clinics that are ready to complete the level 3 certification and move forward with corrective actions for other clinics to achieve level 3 certification. Communication Plan Monthly reports at each clinic s quality council meeting Benefits: Improve patient satisfaction scores, meet ACO criteria, improve quality of care

14 Lean/6 Sigma Project for Answering Service Define Problem: Each clinic is using an outside answering service for after hours calls and to page the on call physician when needed. There are inconsistencies in the coverage utilized from clinic to clinic. The services offered by the current services are limited and inconsistent. There is currently no Ask a Nurse line included in our coverage. Goal: By June 30, 2012, define future state options for a more consistent answering service option possibly with an Ask A Nurse feature and call triage. Scope: Coverage and handling of after hours and noontime calls. Deliverables: Recommended solution(s) for the future state with cost benefit analysis and timeline for implementation. Analyze List potential solutions to fix identified gaps-completed Identified Pro s, Con s, When, Where, Who, Equipment Needed and cost of each solution- Completed Review solutions with upper management to determine the best solution- In Process Measure Gather information on current situation and history- Completed Review current call groups Review current setup at each clinic Measure types of calls coming into the system Map out Current State Process- Completed Identify VOC (voice of customer) and Mercy requirements- Completed Identify gaps in the current process-completed Improve/Control Immediate Short Term Actions: None identified at this time Long Term Actions: Detailed future state process map Implementation plan Communication Plan Benefits: Cost Savings: TBD Aid to Medical Home Requirements Customer Satisfaction: Standardize after hour care for patients

15 Lean/6 Sigma Project for Medicare Wellness Exams Define Problem:. Between January 1 and June 30, 2011 MercyCare providers saw 15,928 Medicare patients. Only 2% of these patients have completed the wellness exam. Providers are missing out on potential revenue generation from performing these exams. Goal: Complete wellness exams on 80% of Medicare patients Scope: Includes MercyCare clinics, excludes Urgent Care Deliverables: Develop processes for conducting the exams Develop templates and education material Work with providers to make the program successful Analyze Develop a future state process map on how the Medicare Wellness exams will be conducted- Complete Review ROI of conducting the exams- Complete Develop templates and education materials- In Process Determine if conducting the Medicare Wellness Exams is worth the time and effort- In Process Measure Gather information on current situation and history- Complete Map out Current State Process- Complete Determine Wellness Exam requirements and reimbursements for the exam-complete Identify VOC (voice of customer) and Mercy requirements- Complete Identified potential hurdles to success- Complete Improve/Control Immediate Short Term Actions: Conduct pilot at a clinic to determine feasibility of conducting the exam- In Process Long Term Actions: TBD-Based on outcome of the pilot Benefits: Better preventive care for patients Possible revenue generation opportunity

16 Lean/6 Sigma Project for Increasing Patient Retention Define Problem: As a system, post-visit communication to patients is inconsistent. Overall, this is contributing to a 1.09% decrease in patient retention from FY10 to FY11 and the missed opportunity of $266,915 in revenue from repeat visits. Goal: An increase of X points for Press Ganey score for Likelihood to Recommend question. Ability to let all current patients know we are: Healthcare providers who focus on keeping you healthy A partnership with your healthcare provider, where you receive consistent care and there is accountability on both ends. Healthcare providers who make sure you get a yearly check-up and recommended screenings. Scope: Communication post-visit to family practice patients. Return visits only. Deliverables: Determine to what extent patients are returning. Measure number of patients who received communication post-visit to determine if the process increased return patient visits Research various vendors to determine the ROI of programs that connect with patients to schedule preventive screenings to determine if we should adopt a similar program. Develop a process for consistent communication post-visit Analyze Develop a future state process map(s) on patient post visit communication- In Process Develop cost effective ways to educate patients post visit- In Process Standardize templates, education material, etc. that goes to the patient- In Process Measure Gather information on current situation and history- Complete Conduct benchmarking of other clinics internally and externally-complete Identify VOC (voice of customer) by conducting a survey- Complete Identified potential hurdles to success- Complete Improve/Control Immediate Short Term Actions: Develop communication plan for improvements- In Process Long Term Actions: TBD Benefits: Better education and assistance for patients Possible revenue generation opportunity

17 Lean/6 Sigma Project for MercyCare/MMC Quality Rewards Program Define Measure Problem: To ensure excellence in patient care and maximize revenue, we must improve our performance in the MercyCare Quality Measures program and make the program more robust Goal: Improve average metrics on the quality program for nicotine assessment from 65% to 90%, and cessation advised metric from 60% to 70% Accomplish 85% in quality measures of HTN, Foot Exam and Microalbumin Gain 95% participation in MMC Quality Program Make program more robust by adding additional metrics by December 2010 Gather information on the current situation and history- Complete Determine inputs, outputs, suppliers, & customers to the process- Complete Identify VOC (voice of customer) feedback- Complete Identified potential hurdles to success- Complete Identify current gaps- Complete Analyze Root Cause of the gaps identified- Complete Improve/Control Immediate Short/Long Term Actions: Implement corrective actions to root causes- In Process Develop controls to monitor gains from improvements Benefits: Better preventive care for patients Possible revenue generation opportunity

18 Lean/6 Sigma Project for Meaningful Use Attestation Define Problem:. In 2011, the Meaningful Use program was established offering a maximum reimbursement of $44,000 /provider over a 5-6 year window (in three stages) if the program is started by Goal:100% certification for eligible providers Scope: All providers that meet the criteria as laid out in the Meaningful Use program for year 1, stage 1. Deliverables: Metrics to track the individual measures for the program Develop processes as needed Determine owner of year 1 stage 1 certification & moving forward Measure Gather information on current situation and history- Completed Map out Current State Process- Completed Determine Suppliers, Inputs, Outputs, and Customers to the process- Completed Identify VOC (voice of customer) and Mercy requirements- Completed Determine Critical to Quality (CTQ s) for Meaningful Use- Completed Identified potential hurdles to success-completed Analyze Compare other quality measures to determine if Meaningful Use items are currently being tracked- Completed Use Practice Analytics to create dashboards to track Meaningful Use measures- Completed Determine which areas the Meaningful Uses requirements are not being met and develop corrective action plan- Completed Improve/Control Immediate Short Term Actions: Communicated to groups that were not meeting the requirements and worked with them to meet the goals Owner for tracking year 1 stage 1 certification has been defined Long Term Actions: Developed a detailed tracking sheet for providers to let them know where they stand on the criteria- Completed Benefits: Realizable Financial Impact: Over $2M for the organization Aid to Medical Home Requirements

19 Collaborating for Quality: UI Health Care and Mercy Medical Center Goals: Position and strengthen both organizations for the future, while remaining independent. Offer better, more comprehensive and coordinated patient care. Why Collaborate? Health care reform is pushing transformation of the delivery system. Many Challenges: fragmentation of care, escalating costs, changing reimbursement, growing competition, uncertainties of reform. Collaboration will position us for the future as we implement many facets of health care reform to further improve the quality of care we provide.

20 Collaborating for Quality: UI Health Care and Mercy Medical Center Initial Focus in 4 Key Areas: Medicare ACO We will develop a more integrated system of care to manage the health of patients. EPIC UIHC will support MMC with EPIC implementation. We will be able to share clinical data, best practices and software. Dialysis We will give patients access to the most comprehensive and advanced dialysis program. Trauma/General Surgery UIHC will provide 24/7 emergency surgical backup until a long term plan is finalized to keep MMC a Level III Trauma Center

21 Patient Visits, April 2012 Prioritizing Lean/6 Sigma Projects Press Ganey scores and benchmarking percentile for the Access section. Includes questions about the ease of scheduling appointments, courtesy of registration staff, etc. 3,500 3, , 33% 91.1, 63% 2,500 2,000 1,500 1, , 72% 90, 51% 90.8, 59% 93.1, 84% 89.6, 46% 92.8, 81% 93.9, 91% 91.2, 64% 90.7, 58% 90.4, 55% 90.8, 60% 0

22 Conclusion As we implement large-scale changes like the Patient Centered Medical Home model throughout complex systems it s important to find a way to make the process more efficient. Lean/6 Sigma methodology gives us a way eliminate waste to reduce costs, standardize throughout a system easily and control our processes for the best possible outcomes. Utilizing Lean provides a structured process to begin implementing PCMH. The many criteria of PCMH are organized and broken down smaller projects to make implementation an easier, team effort. MercyCare uses Press Ganey patient satisfaction scores to prioritize Lean projects. Lean/6 Sigma methodology improves the quality of care we provide.

MERCY-CR/UI HEALTH CARE ACCOUNTABLE CARE ORGANIZATION Dan Fick, M.D. Timothy Quinn, M.D.

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