Re-Engineering Lean Care Management and Automation in a Value-Based World

Transcription

1 Re-Engineering Lean Care Management and Automation in a Value-Based World Jerry Green Kristy Sanders March 30, 2016

2 Housekeeping 1. Using the control panel Use the control panel on the right side of your screen to minimize and expand this panel by clicking on the arrow in the upper right corner. 2. Ask Questions You can submit questions using the Question section located near the bottom of the control panel. We will take time to answer as many questions as we can during Q&A at the end of the presentation. If your question was not answered, we will respond to you individually after the event. 3. After the webinar We want your feedback! Please take the short survey at the completion of the webinar. Also, all registrants will receive a copy of the presentation, and the recording for on demand replay.

3 Agenda Why LEAN and Automation? The five LEAN Steps & Strategies 1. Value 2. Map 3. Waste-flow 4. Implement-Pull 5. Maintain-Perfection In Conclusion Q&A

4 K WHY LEAN AND AUTOMATION?

5 K Why LEAN? To Optimize all three bubbles Automation Solutions Tools Technology IBM WH EMR MIDAS Etc Processes Process Ways of Working Training & Experience People Knowledge, Skills, Abilities

6 K New technologies change the way people work

7 K An uninterrupted flow for the patient is the end goal All team members ebb and flow to keep patient moving through the work flow without waiting or interruption Patient is ready with Labs, Med list, etc Percentage of No Shows reduced with remind Team members collaborate in huddles to prepare for patient arrivals Patient is at the top of the clinical universe Downstream wait time is eliminated as workers and supplies are ready when the patient arrives Process flow optimized and aligned to the technology Upfront pre-visit planning eliminates downstream rework cycles Chart not meant to be read Upfront pre-visit planning is most efficient at reducing care gaps. All other methods require getting the patient back in the office. They re already here! All team members work at the top of license (what is legally allowed]

8 DEFINE VALUE FROM THE PATIENT S PERSPECTIVE

9 Brainstorming using the KANO Model can help identify patient satisfiers and dissatisfiers Kano Model Satisfaction If included, patients/customers will be satisfied If omitted, patients/customers will not be dissatisfied Wow: Delighters Patients don t know it exists. Dysfunctional Items move down over Time Expected: Patients clearly ask for this Functional Basic Needs: (Must Haves) Patients expect this without having to ask for it If included, patients/customers will NOT be satisfied If omitted, patients/customers will be dissatisfied Dissatisfaction

10 K KANO What s important: To not forget Basic Needs To reaffirm what the customer s are asking for, the Expected Needs Not trading Basic Needs for Wow s To ensure that all stakeholder needs are cared for in the new design

11 K No Charter No Project Problem: Lower HbA1c for diabetic patients with scores >=9 Entity: Patient Goals: Improve HbA1c testing rate by 5% by end of Q? Less than 15% >9 by Q? Champion: CMO Project Leader: Quality Manager Project Team: SME s Due Date: dd/mm/yyyy

12 MAP THE VALUE STREAM AND IDENTIFY ISSUES

13 To identify all inputs for a process use the 5M & P Method People Method Machine Material Measurement Mother Nature Physicians Nurses Analysts Patients Programmers Etc Processes Methods Check Lists Approaches Workflows Etc... Laptops Medical Eqp. SW Programs Vehicles Routers Etc Sponges Paper Glue Tile Desks Etc Thermometer Story Points Blood Pressure Lab Scores Coordinate Etc Temperature Rain/Wind Policies HIPAA NCQA ISO Etc

14 K Using the 5M s & P method can help identify what goes into the map Brainstorm for each item and place on a sticky note next to the appropriate 5M & P heading Methods Processes Materials Supplies Mother Nature Policies, Weather Measurement System How things are measured Machines Equipment, HW & SW People Any person

15 Always map the current state in detail Start here Effective change agent Evokes an emotional response Becomes a common language Identifies sources of waste (NVA) Identifies the potential inputs, actions and decision points that may impact a process and its outputs and then it ends here Serves as the foundation for process improvement activities Visual and engaging! Easy to do!

16 Use the LEAN criteria to identify non-value add activities (NVA) in the map The LEAN criteria 1. The patient must care about it AND 2. The activity must change the patient or knowledge about the patient AND 3. The activity must be done right the first time

17 To identify non-value added activities, it helps to think about the 8 LEAN Wastes in the Muda Wheel Defects Motion Over - Production Waiting Waste muda Non Value Added Processing Transportation Inventory Unused Employee Talent Defects - incorrect data entry, incomplete information, mistakes Overproduction - Preparing extra reports, making too much Waiting Batching work, downstream step is not ready unused Creativity - Not working at the Top of a License Transportation - Travel to/from facilities, walking to copy machine Inventory - Purchasing supplies in bulk and storing in cabinet Motion - Extra steps and movement during an exam Excess Processing - multiple sign-offs, most meetings, downstream inspections, rework, approvals

18 K Using a Fishbone (Ishikawa Diagram) with the 5M s and P and the 5 Why can help identify root causes 1. The Problem statement is the Fish head 2. Use the 5Ms and P as the major bones 3. Use the 5 why process with each failure mode to move from symptoms and get to the root causes for each bone 4. Place the root causes on the diagram as smaller bones

19 ELIMINATE WASTE AND ALLOW THE PATIENT TO FLOW THROUGH THE VALUE STREAM WITHOUT INTERRUPTION.

20 Ensure continuous flow in your design so the entity (patient) never waits IDLE WORKERS VS IDLE PATIENT

21 Waste elimination Strategies at a 50k foot level Once Waste is identified: 1.First Priority: Eliminate (do not improve an activity that should be eliminated) 2.Second Priority: Automate Poka Yoke Auto populate 3.Third Priority: Simplify Reduce handoffs Eliminate redundancy Co-locate and sequence tasks Reduce approvals Standardize Reduce motion Prioritize efforts Balance resources One piece flow 5S

22 One way to ensure defects are eliminated is through Poka Yoke and Automation Definition of Poka-Yoke : Japanese for Mistake-Proof Two Types Detection detects defects which have already occurred Prevention predicts and/or prevents defects from occurring Error Proofing Spectrum Passive Reactive Proactive None Instruction Training/ Visual Aids Visual Guidelines Containment 100% Inspect Defect Detection Warning Shutdown Defect Prevention Control Awareness Most processes Detection Prevention

23 K Poka Yoke Ideas Reduce NVA by eliminating rework loops, auto populating data entry Drop down menus for data entry Color coding items that go together Manual processes automated (not manumated) Electronic sensors for danger areas Bar coding Collision detection systems Correct position setting tape so item is always placed in the correct location Barriers to electronic files Computerized Physician Ordering Systems Plug protections for children

24 K Ideas for Leaning out the 8 Types of Waste Type of Waste Definition Example Solution Defects Over Production Waiting unused Creativity Errors resulting from omissions, inaccurate information, or mistakes. Often results in lost capacity from rework and can cause harm. Providing more services that needed, including redundant services. Idle time for the patient usually due to waiting for needed information, action, or resource. Unused talent an skills. Not working at top of license and legal allow ability. Use algorithms to evaluate patient care gaps against evidence-based guidelines and take action to close them with automated patient communications & provider alerts. Query integrated patient registry before ordering tests and services for patients. Build in same day appointment slots to improve access; redesign visit preparation process with daily huddles and new roles for care team members while rooming patients. Train medical assistants to do health coaching; delegate or automate nonclinical tasks to maximize use of clinical team members specialized skills. Source: Handmaker, K., Green, J. (2014). Lean Care Management and Automation. Retrieved from April 15, 2015.

25 K Ideas for Leaning out the 8 Types of Waste Type of Waste Definition Example Solution Transportation Inventory Motion Excess Processing Moving people, equipment and supplies. Walking or driving to and from. Represented by the lines in a value stream map. A supply of resources stored while waiting to be consumed by patient demand. Movement when in a stationary area while performing tasks. More work being done than what is required by the patient. Includes doing more that than absolutely necessary. Do lab testing in the office instead of sending patients to another location. Survey patients to determine best days, times, and locations to hold group education sessions so supply matches demand. Co-locate physicians and medical assistants in pods to eliminate extra steps to communicate (messaging, walking); utilize automated reporting and alerts to minimize clicks and research time. Ask patients to only update new information instead of completing the same profiles at every visit. Source: Handmaker, K., Green, J. (2014). Lean Care Management and Automation. Retrieved from April 15, 2015.

26 IMPLEMENT THE IMPROVED PROCESS AND LET THE PATIENT PULL THE VALUE THROUGH THE PROCESS.

27 Kotter s 8-Steps can help with change management Kotter s 8-Steps for Managing Change 1. Create a sense of urgency 2. Form a guiding coalition Those who can help move the project forward Up and down the organizational hierarchy 3. Create a vision of the future 4. Communicate the vision 5. Empower action 6. Create short term wins 7. Don t let up 8. Make change stick

28 What is Pull? No one from an upstream process, step or activity produces or moves the entity until the next downstream process, step or activity is ready for it I m ready! Pull Step 1 Step 2 Step 3 Step 4 Step 5 Using a pull system makes delays and waiting transparent, pushing tends to hide the amount of time a patient waited in the system Transparency helps with optimizing scheduling Less wait = higher patient satisfaction Less wait = increased velocity through the system 28

29 MAINTAIN THE GAIN AND PURSUE PERFECTION

30 Tweak to perfection using 5S 1. Sort: Keep only what is needed, discard everything else. Sort remaining into categories 2. Store: A place for everything and everything in its place. Store and label all items in an area that is easily visible and accessible to the group. 3. Shine: Keep the workplace tidy and organized and labels obvious. Clean and tidy up regularly. 4. Standardize: All areas must be set up exactly the same way. Makes standards obvious and enforce them. 5. Sustain: Maintain, plan, schedule, train, track and audit all areas periodically.

31 Compare before and after measures Measure Before VS After and report on improvement Before After

32 Monitor and Close: Pursue Perfection Go back and review the Charter and patient values from the KANO Redefine new and tougher targets Find additional waste to remove using the LEAN Criteria It takes about 90 days for a change to stick Only the Champion can close the project Must insist on evidence that the project was successful and when doing more is not worth the cost to continue Monitoring and measuring the key measures must continue FOREVER

33 IN CONCLUSION

34 Processing Approvals Rework End to end

35 K Why LEAN? To Optimize all three bubbles Automation Solutions Tools Technology IBM WH EMR PeopleSoft Etc Processes Process Ways of Working Training & Experience People Knowledge, Skills, Abilities

36 A Guide to Lean Healthcare Workflows This free guide delves into the five steps of LEAN as a detailed walkthrough: 1.Define value from the patient's perspective 2.Map the value stream, and identify issues and constraints 3.Remove waste, and make the value flow without interruption 4.Implement the solution, and allow patients to pull value 5.Maintain the gain, and pursue perfection

37 QUESTIONS?

38 THANK YOU! The recording and handouts will be sent to you via within 2 business days