2013 Virginia Mason Medical Center

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2 Objectives Recognize the challenges to Ambulatory Clinic Flow Apply Lean Tools and Methods to Improve Clinic Flow Describe the benefits of Team Based Care

3 A Day in the Life of a Primary Care Provider

4 The Burden of Work Practice improvements often fail because they rely on the willingness of physicians who are already too busy to take on additional work. Bodenheimer, T., Coordinating Care A Perilous Journey Through the Health Care System, NEJM; 358:10, p1064, 2008

5 Ambulatory Care Care Production System PROCESSES Appointing Arrival Rooming Exam Discharge Greet Patient ID Agenda Prev. Care Vitals OPERATIONS

6 High Quality Care Starts by Removing Waste Inventory Processing Time Defects Overproduction Motion Transportation

7 Three Common Wastes Burden Our Work and Prevent Flow Time in Batch Process Piles of messages, documentation and correspondence Patients waiting Excess inventory Defects Rooming mistakes Patients scheduled for the wrong provider Medication errors Neglected tests and vaccines Overproduction Staffing costs Excessive normal imaging Antibiotic resistance

8 Batch Production

9 Flow Production

10 Foundational Elements for Flow Workshop

11 5S Workplace Organization Self Discipline: Maintain standards through training, empowerment, commitment and discipline Sort: Separate necessary from unnecessary Standardize: Create common agreements Communicate to the team Sweep: Inspection that everything is where it belongs Visual confirmation that 5S agreements are being followed Simplify: A place for everything needed, in its place and ready to use

12 S Exercise ross out the numbers from 1 49 in order, 20 Seconds

13 Sort Cross out the numbers from 1 49 in order, 20 Seconds

14 Simplify Cross out the numbers from 1 49 in order, 20 Seconds

15 Simplify Cross out the numbers from 1 49 in order, 10 Seconds Numbers from 1 to

16 Sweep What s Missing?, 5 Seconds Numbers from 1 to

17 Standardize Cross out the numbers from 1 49 in order, 5 Seconds Numbers from 1 to

18 Foundation for Clinic Flow: 5S Workplace Standardization 5S in the clinic includes: Work surfaces Exam room surfaces and drawers Procedure rooms Supply closets/supply inventory Schedule closet and patient inventory and just about everything

19 Results: Early gains from 5S Trend of Average Supplies Per Month $140,000 $120,000 $115,023 Total Supplies Expense (Medical, Office, Other) $100,000 $80,000 $60,000 $40,000 $20,000 $98,866 14% Reduction '03 to '04 5 % Reduction 04 to 05 $93,959 $- Source: FM-BSR; 8 satellite locations Year 2009, Virginia Mason Medical Center

20 5S: Clinic Schedule Dept Primary Care ACCESS & SUSTAINABILITY PILOT Elongate the scheduled work day by adding indirect care pauses As indirect care needs increase, need to better flow indirect care into day Despite longer scheduled clinic, provider home earlier DC 20 DC 20 DC 20 IDC 20 DC 20 DC 20 DC 20 IDC 20 DC 20 DC 20 DC 20 IDC 20 DC 20

21 Maintaining Clinic Flow: Set Up Reduction Vaccines Biopsy Prep, LN2, PHQ9, Eye Tray, etc. Exposed body part ready for procedure Spreading care to Care Managers Time planning through daily team huddles Endometrial Biopsy Kit

22 Standard Work Without standards, there can be no improvement. Taiichi Ohno Founder of the Toyota Production System

23 Standard Work: Direct Care Standard Process Description Rooming Sequence Takt Time: 9.6 minutes Who Must Adopt This Process: Flow Manager Primary Care STEP OPERATOR TASK DESCRIPTION TOOLS/SUPPLIES REQUIRED CYCLE TIME 1. ROOMER or FRONT DESK Load appropriate template onto Cerner, change author to PCP, save and close. Print 007 report (if PCP report is unavailable), and Problem Summary List (PSL). Attach PCP or 007, PSL with green billing slip, patient labels. 1 min 30 sec 2. ROOMER Call patient from waiting room, ID patient with name and DOB. Weigh patient and use chart to calculate BMI (either ask for height or measure patient). 1 min 20 sec 3. ROOMER Enter exam room, patient sits in chair. Use PCP/007 form and Health Review Screen Form to confirm with patient if health maintenance is up to date. 1 min 36 sec

24 Standard Work Direct Care: Pre Visit Phone Call Set up for New Complex Patients Appointment date: _ Patient Concerns for appointment (in order of importance to patient): 1 st : _ 2 nd : _ 3 rd : _ Allergies updated Yes [_] No [_] _ Medications updated Yes [_] No [_] _ Family History updated Yes [_] No [_] _ Social history updated Yes [_] No [_] _ HMM reviewed Yes [_] No [_] _ Records requested Yes [_] No [_] _ [_] Permission received to request records

25 Standard Work: Indirect Care Forms Set Up

26 Standard Work Indirect Care: Outside Medical Records

27 Maintaining Clinic Flow: Standard Work Huddle and Pre Visit Phone Call During the huddle, the provider identifies which patients on tomorrow s schedule the Flow Manager should contact to review: Agenda setting Medication and Allergy review Family/Social history 3. FM or Designee 4. FM or Designee Create new phone message titled: FM/Provider Name/Pre Visit/Appt Day Create Pre Visit Set up autotext by copying text below and saving in Cerner as autotext named.pv. Stamp.pv into Cerner message. Pre Visit Set up Appt date: _ Patient Concerns for appointment (in order of importance to patient): 1st: _ 2nd: _ 3rd: _ Allergies updated Yes [_] No [_] _ Medications updated Yes [_] No [_] _ Family History updated Yes [_] No [_] _ Social history updated Yes [_] No [_] _ HMM reviewed Yes [_] No [_] _ Records requested Yes [_] No [_] _ [_] Permission received to request records Ask: Can you share with me now the concerns you wish to discuss with Dr. at your upcoming appointment? Ask Is there anything else? If more than 3 concerns, say It is possible you won t have time to get to all of those concerns in this visit, but we ll do our best; I just want you to be prepared that we may need to schedule a second appointment to make sure to do justice to all of your concerns. Complete message template portion: Pre Visit Set up Appt date: _ Patient Concerns for appointment (in order of importance to patient): 1 st : _ 2 nd : _ 3 rd : _ Cerner Power Chart Cerner Power Chart

28 Standard Work: Documentation Template design embeds EB care MA sets up and starts documentation Provider documents in flow (concurrent with exam) Documentation time reduced Medical assistant completes blue portion

29 Standard Work Direct and Indirect Care: Skills Map

30 Flow of Patients Flow of Family and Relationships Flow of Providers VMPS Flows of Medicine Flow of Medications Flow of Supplies Flow of Information Flow of Equipment Flow of Process Engineering

31 Flow Management at Flow Stations Eliminates walking Continuous flow (no batching) Visual control Line of sight MD and MA side by side Results Reporting Sign & Review NON URGENT Outside Records Signatures Referral Forms URGENT Critical Results Access Patient Concern ELECTRONIC MESSAGE CHARGE SLIP $ DOCUMENT VISIT MD MA

32 Flow Station at Virginia Mason

33 FLOW STATION VIDEO

34 Achieving Continuous Flow Flow Stations A Flow Station is a specific work area for the team Next to exam rooms Designed to allow completion of indirect patient care tasks between patient visits Uses simple, sequential steps Gets today s work done today!

35 How to Implement a Flow Station 1. Create a workspace Preferably at standing height Locate with line of sight to exam rooms 2. Establish a standard sequence of work FM: Start with the rooming process and external set up Provider: Determine items to be completed between each patient visit 3. Write standard process for FM and Provider 4. Use visual controls to identify tasks at a glance

36 Standard Work Sequence at Flow Station Finish the first patient Completion of documentation and charge slip for patient just finished Indirect care Forms Electronic messages Rest results reporting Phone calls to patients, etc. Prepare the next patient Set up for next patient

37 Indirect Care Flow Standard Flow Station Boxes Front Flow Water Strider Flow Manager MD

38 Maintaining Clinic Flow: Mistake Proofing Health Maintenance Module

39 Maintaining Clinic Flow: Mistake Proofing Health Maintenance Module 100% Overall Seven VMMC Primary Care Clinic Utilization of HMM October 2008 March 2010 Compliance with Prevention 80% 60% 40% 48% 68.5% 71% 70% 68% 82% 81% 75% 78% 80% 83% 88% 83% 80% 80% 82.5% 76% 68% 20% 0%

40 Maintaining Clinic Flow: Mistake Proofing Overproduction

41

42 Maintaining Clinic Flow: Mistake Proofing Imaging GO/NO GO MRI ORDER Order must fit evidence based indication for imaging

43 Maintaining Clinic Flow: Mistake Proofing Imaging Mistake proofing implemented Reduction in imaging Headache: 23% Low back pain: 23% Sinusitis: 27% J Am Coll Radiol 2011; 8:19 25

44 Maintaining Clinic Flow: Level Loading 22 HOURS/DAY Prevention Patient Education Care Coordinator 10 hours/day 2 hours/day 2 hours/day Practice improvements often fail because they rely on the willingness of physicians, who are already too busy, to take on additional work. 8 Hour Day Tom Bodenheimer Direct Patient Care 7 hours/day 0 PHYSICIAN (Based on a panel size of 2000 patients)

45 Maintaining Clinic Flow: Level Loading Skill Task Alignment RN PATIENT MA A multidisciplinary team Skills aligned with tasks needed for complicated patients AHP MD PHARM

46 MEDICAL ASSISTANT: Standard rooming sequences Review Health Maintenance Module Shared documentation Coordinating provider flow through the day RN: Patient assessment Empowerment of patient for self care Protocol driven teaching and coaching for chronic conditions Nursing procedures PHARMACIST: Medication management for chronic conditions Advanced protocols for disease state management PROVIDER: Diagnosis and treatment of new problems Oversight of complicated problems Minor surgical and diagnostic procedures Mentor and coach for team based care

47 Maintaining Clinic Flow: Level Loading Skill Task Alignment HOURS/DAY Patient Flow Manager Physician RN Care Manager NP/PA Pharmacist IT

48

49 Testing the Team Model Boeing Project Improve health status of the most costly patients 1. Team based care that is evidence driven 2. Immediate care: same day access with 24/7 phone and 3. Individualized care: custom education and shared decision making 4. Anticipatory care: avoiding predictable problems 5. Coordinated care: connecting all other providers

50 Overall Costs Decreased 20% Greatest Benefit: Avoiding Hospitalizations -100% -80% -60% -40% -20% 0% 20% Costs (standardized) Prescriptions (day supply) Prescriptions Out-patient (other) Home Health Visits Dental Lab Radiology Outpatient Visits Office Visits ER Visits Hospital Days Admits

51

52

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54 Family Practice Margin Virginia Mason Kirkland: 4.3 FTE $2,000,000 1,759,163 $1,500,000 $1,000,000 $935,834 $1,010,072 $500,000 $0 ($500,000) ($1,000,000) ($716,391) ($332,983) Year 1 Year 2 Year 3 Year 4 Year 5

55 In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists. Eric Hoffer 2011 Virginia Mason

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