Creating the Lean and Efficient Medical Practice

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1 Click to edit Master title style Creating the Lean and Efficient Medical Practice Chris Calderone M-CEITA / Altarum Institute March 5, /5/

2 M-CEITA Services Meaningful Use Stage 1 Support On-site support, including MU reports, actionable steps for resolving issues and technical support. Meaningful Use Stage 2 Support Technical assistance, including workflow redesign, security risk assessment and MU compliance. (e.g. patient portal and clinical quality measures) Security Risk Assessment Support meeting the requirements of Core Measure 15: Protect Electronic Health Information, including an assessment using our exclusive tool. Targeted Process Optimization (Lean) A workflow analysis and redesign of core processes using Lean principles to increase efficiency and reduce duplication. (e.g. chart prep, doc. Management) Audit Preparation A review of Meaningful Use attestation documentation using our exclusive Audit File Checklist, to correct any issues before completing the process. 2

3 Chris Calderone, MA, MBA Performance improvement and lean consultant focused on helping healthcare providers apply lean tools, concepts, and techniques designed to improve core processes and optimize workflow Extensive lean experience across the care continuum - (hospitals, clinics, and physician offices, home health) Credentials include: Lean Healthcare certified, MBA, master s degree in organizational management 3

4 Overview of Discussion Provide an introduction to lean thinking for healthcare providers Discuss how lean process improvement techniques can be applied to a medical practice Discuss common medical practice pain points Review forms of waste within a practice Review techniques on how to begin improving processes using a lean approach 4

5 Defining Lean A performance improvement approach that focuses on reducing the different forms of waste that we encounter in our daily work A set of concepts, principles, and tools used to create and deliver the most value to the customer Referred to as Lean Thinking Widely (and successfully) applied to many areas of healthcare- can also be applied to a medical practice 5

6 A Few Key Questions to Consider. 1. Is it possible to minimize the non-value added activity (or waste) within a practice? 2. Can we improve processes so they are more patient-focused and more efficient? 3. Can we free-up more time for physicians? 4. Can we reduce barriers and staff frustration? 5. How can we improve patient flow in a medical practice? 6

7 Defining Patient Flow The process of how patients enter, move through, and exit the practice an ideal patient flow means: - Less waiting (stopping and re-starting) - Minimized handoffs (info, paper, patients) - No duplication - Minimal searching (for information and things) - Reduced cycle time Each is an ideal improvement focus for a lean approach Patient flow is measured in cycle time 7

8 Understanding Cycle Time Cycle time (throughput time) is the time from the patient s entry (patient sign-in) to patient exit The total cycle time in a medical practice typically ranges from 30 to 90 minutes Can be much higher in specialty practices Cycle time has two primary components: -Value-added activities -Non-value added activities (waste) 8

9 Waste Key Points Non-value added activities time/resources spent that prevent us from optimizing patient care (and prevent us from optimizing physicians time) Examples: - A slow scanner that slows down registration process -Slow computers/software -Paper-intensive environment -Last-minute cancellations and no-shows that can impact the daily capacity of the practice 9

10 Searching for test results in a pile of paperwork! 10

11 More Examples of Waste Adding extra (unnecessary) steps to a registration process (registration should take about 10 to 15 minutes for new patients) Taking too much time to schedule appointments These are all forms of waste that can add minutes to cycle time and impact patient flow (and revenue)! Can also impact both staff and patient satisfaction 11

12 Waste Up to 50% of your time is spent doing things that create little or no value for your customer! Some things are non-value added but we have to do them anyway these are essential non-value added activities 12

13 Categories of Waste Transportation (motion of things) Inventory (too much stuff) Motion (movement of people) TIM WOOD Waiting (patients, staff) Over-processing (duplicate charting) Over-production (too many tests) Defects (errors, re-dos) 13

14 Examples of Waste in Healthcare Type of Waste Description Examples Defects (errors) Work has defects has to be corrected (or reworked) Medication errors, incomplete orders, illegible orders, errors of omission and commission Waiting Excess time when people, information, or supplies are not available Waiting for a room, waiting for a test, waiting for a nurse, doctor Overproduction More is produced than necessary Asking patients the same questions over and over, ordering tests that are not needed Motion Motion of people that does not add value Searching for information, supplies, walking from point A to point B (excessive footsteps) *Confusion Lack of standard work not knowing what to do Informal processes, inconsistency in terms of who, what, how, and when daily tasks are carried out 14

15 Waste Identification Where is the waste in your practice? Waste Identification exercise tool A good starting point have to be able to see the waste and recognize it if you are going to eliminate it! Practical and easy - very insightful 15

16 Waste Identification Exercise Category Description Justification (Why is this considered waste)? Transportation tool Inventory Motion Clerk or nurse looking for paper chart Spending about 20 minutes per day walking from point A to point B looking for and gathering paper Confusion Waiting Over-processing Asking patient for same information (HIPPA sig, demos, allergies, etc.) Redundant duplicate work and in most cases. Is probably unnecessary Over-production Defects Instructions: Now that you are familiar with the seven forms of waste in lean, think of your specific area of responsibility or the specific processes in which you work using the definitions of the various forms of waste, identify specific examples of waste in your area for each of the waste categories identified above. Definition of Waste: Any healthcare service that consumes resources yet does not add value to the patient or customer 16

17 Reducing Cycle Time Cycle time consists of waiting and delays things that do not add value A lot of starting and stopping Waiting for next step/person, waiting for information How can we decrease cycle time (decrease the waste)? 17

18 Cycle Time Do you know your average cycle time? -Easy to determine -Get a snapshot of current cycle time -Record time when patient enters, and record the time patient exits the practice Once overall cycle time has been determined, find out where the delays and waiting are occurring within the sign-in to exit of overall cycle time 18

19 The Typical Patient Visit Start Patient Calls for Appointment Patient Checks In Patient Waits in Waiting Room MA Sees Patient Phone is busy Patient calls repeatedly First available appointment is scheduled (2 week wait) Arrives at the wrong clinic Duplicate patient records in the system No exam rooms are available Waits 20 minutes Med list and allergy list are outdated Chart is missing a recent ER visit report Patient Waits in Exam Room Waits 10 minutes MA makes calls for prior authorization Provider Sees Patient Patient is overdue for screenings Patient shares critical info at end of visit Provider gives referral, meds - Patients will tolerate about 20 minutes of wait time - Patient loyalty is challenged when the wait exceeds 10 minutes Patient Checks Out Referral takes 10 days Meds not covered by insurance Wrong code on patient bill Stop Sub-Processes Think of cycle time as the overall process that starts when a patient signs in and ends when the patient leaves. There are many subprocesses that have their own start point and end point within overall cycle time it s helpful to understand other subprocess times 19

20 The Economics of Waste There are many steps involved when a patient checks in and out Every patient visit has some waste you can t eliminate it completely, but you can try to minimize the waste It is common to find about three minutes of waste (or non-value added activity) per patient visit Seconds and minutes can add-up quickly 20

21 Maximizing Capacity Saving minutes can result in the ability to see more patients Shaving 1-2 minutes per patient visit can provide additional capacity to see 2-3 more patients per day Everyone plays a part in reducing cycle time anyone that touches the patient from sign-in to exit The role of the physician 21

22 What is the Most Valuable Asset? A large part of improving flow involves the physician Who can bill for a service in your practice? a) Receptionist b) Physician d) Biller e) Office manager Practice revenue is essentially a function of how the physician uses his/her time 22

23 The Physician s Time Time Typical Practice Ideal Practice Productive 70% 100% Wasted 10% 0% Could delegate 20% 0% 23

24 Maximizing Physician Resources Inefficient use of a physician s time is a constant concern The practice (and all processes) are built around the physician s time What do patients want? The physician s time is what patients want 24

25 The Patient Patient-Provider Time (PPT) is what matters to patients As you consider steps to improve patient flow, consider how they can free up time for the physicians to care for patients Redesigning/improving the patient flow process - a lot of small changes can really add up 25

26 The Power of Small Changes Little things matter such as reducing the excessive footsteps involved in hunting and gathering activities (the waste of motion) Making sure rooms have what you need when you need it (point-of-use concept) Creating a highly organized and functional work area (a lean concept called 5S) Assessing walk patterns 26

27 5S Defined 1. Sort 2. Straighten 3. Sweep/Shine 4. Standardize 5. Sustain Unorganized and cluttered work areas negatively affect productivity, quality, and safety Direct correlation between work area organization and efficient workflow People feel better when they work in a highly-organized and neat work area (and they perform better too) 27

28 Simple Concepts: Office Layout Assess the physical flow of both patients and staff consider office layout, minimize footsteps & motion Staff and physicians working closer together in workstations where they can more easily interact Communication between team members is direct: - Communication delays are reduced - Tasks are more closely coordinated - Wasted motion and wasted footsteps are minimized 28

29 5S Organizing and Standardizing Before After A place for everything and everything in its place! 29

30 5S Office Before and After 30

31 Getting Started Path to Improving Select one improvement opportunity - evaluate and improve a specific process or area (patient flow) Gain a deep understanding of the current state Map the current process flow capture the workflow, sequence of tasks, individuals, etc. If mapping patient flow, it is helpful to map the flow through the perspective of both the patient and staff 31

32 Examples of Value Stream Mapping 32

33 The Typical Patient Visit high-level Patient Calls for Appointment Patient Checks In Patient Waits in Waiting Room MA Sees Patient Phone is busy Patient calls repeatedly First available appointment is scheduled (2 week wait) Arrives at the wrong clinic Duplicate patient records in the system No exam rooms are available Waits 20 minutes Med list and allergy list are outdated Chart is missing a recent ER visit report Patient Waits in Exam Room Provider Sees Patient Patient Checks Out Waits 10 minutes MA makes calls for prior authorization Patient is overdue for screenings Patient shares critical info at end of visit Provider gives referral, meds Referral takes 10 days Meds not covered by insurance Wrong code on patient bill Think about it from the patient's perspective. What does the patient want? 33

34 Question How Things are Done Question the process: What are they doing? Who is doing it? When do they do it? How do they do it? Why do they do it this way? Identify common traits (barriers or potential improvement areas) within patient flow process 34

35 What Issues Surface? Waited a long time for the provider Waited a long time to be registered Waited a long time for the nurse Patient was asked to move around a lot Provider was frequently interrupted during the visit The patient had to fill out a lot of forms The exam rooms didn t have the necessary supplies Staff had to search for stuff 35

36 A Lean Approach Everyone (regardless of role/title) should think about how to increase value to patients Review every step within the entire patient flow process (or the process/area you are focusing on) How to reduce waste consider what is valueadded vs. what is non-value-added 36

37 Detailed Value Stream Map (VSM) Value Added (VA) Non Value Added (NVA) Non Value Added but Required (NVAR) 37

38 Assessing the Value Stream Map Where can we minimize waiting? Can we re-sequnce steps? Can we merge/combine any steps? Can we minimize handoffs? Uncovering Opportunities Can we eliminate any steps? Can we reduce paper? Leverage technology? Standard work (role clarification, procedures and process steps are formalized and well-defined) 38

39 The Power of Seeing Consider casually observing physicians while they interact with staff before and after patient visits What tasks are they performing? How long does each task take? You can observe a lot by just watching. - Yogi Berra How much walking is involved? (note time in minutes) Consider using a pedometer to capture distances travelled 39

40 Traits of a Lean Practice 40

41 Monitor What Matters Monitor key metrics: - Appointment fill rate - Cancellation rate - No show rate (Typical to have 5 to 7 percent of all appointments as no-shows) - Cycle time - Avg. # of days to next available appointment for new patient - Avg. patient wait time (from door to provider) -% of cancelled appointments converted to another appt. 41

42 Use of Standard Work Processes are formalized and documented clarity around who does what, when, where, and how Written documentation of the way each step in a process should be performed Use of standard work tools or guides visual aids/cues that help remind people to perform certain tasks Checklists, process diagrams, one pagers, etc. Helps to ensure consistency and operational discipline 42

43 Checklist - example Title: (Process Name Can use in any area- chart prep, registration, billing, etc. Serves as a visual cue or reminder to prompt key tasks Step 1 Step 2 Step 3 Include key parts of the process or essential must haves Step 4 Step 5 Step 5 Step 7 43

44 The Power of Consistency Process consistency is a critical success factor in effective medical practices standard work is essential You say what you will do (standard work) and you do what you say (accountability) Accountability is really about habit formation It s not just about what, who, and when, it s also about the why of standard work 44

45 Connecting People with the why 45

46 Managing Change Improving always requires change Lean involves the people actually doing the work they are the people that are re-designing the work and making the changes Leaders ensure that new behaviors are engrained into everyday practice habits Change is framed from the perspective of the patient Financial imperative 46

47 Managing Patient Flow Laser-like focus on patient flow everyday, not just when problems/issues bubble-up Take corrective action immediately Know average cycle time More importantly, monitor for delays within the cycle time (the sub-processes tells you where to focus) 47

48 Other Focus Areas Lean concepts and techniques can also be applied to: - Chart preparation - Orders tracking - Referral management - Revenue cycle management Any process/area with delays/waste, and where timeliness, accuracy, and speed matter 48

49 Review of Key Points 1. Lean techniques can provide you with a new approach to process improvement/practice optimization 2. No single sliver bullet a lot of small changes will be required to improve flow (the power of small changes) 3. While technology can help drive consistency and performance it s just a tool that facilitates processes standard work is essential 4. Pick one process/function map the flow, identify the waste, and select potential improvements (OFIs) 5. Manage the change and sustain the gains lean provides more structure, discipline, and rigor 49

50 Reducing the Four Cs Lean (standard work and waste awareness) can help reduce: Confusion Chaos Complexity Conflict 50

51 LEAN can help to us to minimize waste, remove barriers, and allow us to provide more value to our customers (Using fewer resources) Source: Lean.org 51

52 Targeted Process Optimization Tools, best practices, and consulting services related to: Patient flow and general operations Chart preparation Orders tracking Referral management Revenue cycle management TPO Website Less time spent on assessing and evaluating focus is on execution and implementation Can help accelerate the rate of improvement 52

53 Additional Resources/Guidance Onsite operational assessment with a detailed Road Map and Action Plan for improving operations Available now Waste identification tool Available now Operational self-assessment tool (used to surface and Available now develop improvement opportunities) Customized solutions and consulting services Available now Patient Flow ToolKit (self-use tool with coaching) Coming soon 53

54 Access to free operational selfassessment tool A link to access the tool will be sent out to all attendees via 54

55 Questions? Chris Calderone

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