Creating a Lean Culture at Family HealthCare Network

California Improvement Network Presentation
September 29,
29 2010
Steven Palmer, MD
Jay Kelley
Norma Verduzco
Chief Medical Officer
Chief Information
Officer
Director of Operations
Projects & Support Services
Adriana Carrillo
Marisol de la Vega Cardoso
Enrollment Referrals
Director of Quality Improvement
Representative
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Learn how to implement Lean approach in an
ambulatory care setting.
Learn the benefits of Lean healthcare
approach.
approach
How FHCN used a Lean approach for its EHR
implementation this year with no decrease in
productivity.
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Sites: 11 Clinical + 3 Admin
Annual patients: 101,967*
Annual encounters: 492,683*
Clinical Support Staff: 450
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Clinicians: 88
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Dentists: 14
Ancillary Support Services:
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3 Nutritionists
Nutritionists, 1 Registered Dietician
Dietician, 5 Behavioral Health Providers,
Providers
•
1 Chiropractor, 8 Radiology Technicians
*2009 UDS Report
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Lean is a set of concepts, principles, and
tools used to create and deliver the most
value from the customer’s perspective while
consuming the fewest resources.
This is about Overall Performance –Not
Not Silos!
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“Your system is perfectly designed to produce
the results you are getting”
-Frederick Taylor
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•Concept introduced by the CMO
•Opportunity
Opportunity to improve efficiency and to test our
assumptions.
•Reduce duplication of effort in work flows.
•Reduce the beauracracy and hoops to jump through created
by us.
•Opportunity to do something different…we could not keep
on doing the same thing.
•There was a sense of urgency.
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•
Introduction of Lean Concepts:
• Two books became building blocks:
•L
Lean ffor Practitioners
P
ii
(Mark Eaton)
• Sustaining Lean Healthcare Programmes: A
practical survival guide (Mark Eaton & Simon Phillips)
•
Required
q
reading
g for Senior Leadership
p
• Decision made to accept this as a quality improvement methodology
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•
•
Required reading for Leadership Team (Directors
and Managers)
• Operations Team (Supervisors)
• QI Team
• Other departments
Hired a consultant with a “Black
Black Belt”
Belt in Six
Sigma/Lean methodologies to support the
organization to introduce lean concepts for
improvements, in particular to utilize in review and
development of its future workflows leading to
EHR.
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Staff were nominated by their Supervisors
◦ Knowledgeable in their areas
◦ Not afraid to speak up
◦ Open to change;
◦ Team was completely multi-disciplinary
multi-disciplinary.
◦ Consultant used a hybrid of an actual Lean Six Sigma project.
x
x
x
x
Used components of defining the process
Identified project scope
Performed value stream mapping
Activities produced several quick hit processes that could be retooled to
eliminate waste and begin to streamline the process.
x Ease of making an appointment/Phone System
x Wait time associated with getting an appointment and waiting to be
seen
x Completion of paperwork
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D
Define the problem
“Lean” eliminates waste
◦ Voice of the Business
“Six Sigma” reduces
◦ Voice of the Customer
Variation in the process
M Measure the problem
◦ Value Stream Mapping
A Analyze
y for and isolate Root Causes
◦ Customer Requirements
◦ Analyze data using hypothesis, etc.
I Set improvements targeting the root causes
◦ Eliminate waste and create process to meet customer
requirements
C Create Control plan(s) to measure and keep process fixed
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Value added for our patients
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Non-value added and waste
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Consider Business Requirements (Essential
non-value added)
Maximize use off our systems…facilitate
f l
pull
ll
through of the patient through our clinics
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Helps people understand how the process works now
Helps
well
H l people
l understand
d t d and
d reach
h agreementt on how
h
ll
the process is working
Helps uncover waste and problems with flow in the value
stream
Helps people reach agreement on what changes need to be
made
H l people
Helps
l reach
h agreement on how
h
to ensure that
h those
h
changes are made
Helps teach people Lean thinking and tools
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How we used Lean during the implementation
of the
Electronic Health Record
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2/26/09 through 3/3/10 = 370 days
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Data moving into EHR
Demographics
Appointments
HPM (PM System)
EHR sending Data out
EHR
IC-Chart
Lab
ab O
Orders
de s
Quest
Lab Results
Quest
Transcriptions
MxSecure
Rx Eligibility
HUB
g
Charges
HPM (PM System)
Includes:
•Visit Entryy
(Templates)
•Order Entry
•Prenatal
•E
Prescribe
•E-Prescribe
Immunizations
CVIIS/CAIR
E
prescribing and
E-prescribing
E-Faxing
SureScripts
Dental
Dentrix
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EHR Leadership Team
◦
◦
◦
◦
◦
◦
◦
◦
CEO, CIO
CMO,CDO
Medical Directors
IS Project Director & IS Staff
VP of Operations and Operations Directors
VP of Finance & Billing Director
QI & Admin Support
Training Team Members
◦
◦
◦
◦
◦
◦
◦
◦
Providers
Dental Team
Medical Assistants
F
Front R
Reception
i
&D
Data E
Entry & Billi
Billing
Referral & Radiology
Dispensary
Health Information
Central Appointments & Community Rep
Engaged CORE Team – Lean Concept
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Goal: Preserving Value with Less Work in the
development of EHR
Front Line Staff selected
◦ Experienced, Vocal, with initiative, global thinking
◦ Exposed to Lean Concepts with early project in April
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B
Brought
h in
i their
h i expertise
i
◦ Helped evaluate current workflows
◦ Key input for future EHR workflows
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Became part of the Build and
Design Team for IC-Chart
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Breakdown by position
All areas represented
◦ Some Lean Team members
were experts in more than 1
area
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Provided key input on
streamlining current
processes in the future
EHR workflow
Breakdown of Lean Team Representation
Central Appointments
Central Appointments
Community Relations Rep
Health Information
Dispensary Clerk
Enrollment Referral Rep
Radiology Staff
Receptionist & Data Entry
&
Billing Team
Dental Assistant & Reception
Medical Assistants
Dentist
Behavioral Health
Nutritionist
Health Educators
Total
35
15
50
16
15
20
80
18
35
150
15
6
3
18
Lean Representative
1
1
1
1
1
2
1
1
1
3
1
1
1
1
476
17
◦ E.g. Reduction of Forms from
900 to approximately 250.
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p Team Commitment:
Leadership
◦ Tuesdays & Wednesdays committed to EHR as much as possible
Lean Team Participation – Wednesdays
Pulling
g in Subject
j
Matter Experts
p
as necessary
y
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Workflow Design
System Build
Workflow Testing
PDSA - Plan Do Study Act
Communication of Changes
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Weekly Calls with Vendors on Interfaces
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Trainers Active
since
August
i
A
Participating in
Build
u d & Decision
ec s o
sessions
Developed
T i i
Training
Material
PILOT and Final
Modules
Super Users
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Ramp Up
Double Documentation
Clarify & Train & Check-off
Address Issues
Stress Test
F il O
Fail
Over T
Testt
Week 2/8
Week 2/15 Week 2/22 Week 3/1
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Numbers for March
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Visit For the Day:
Labs Ordered:
Prescriptions:
p
Referrals to Specialists Ordered:
In-house Radiology Ordered:
Telemedicine
l
d
Services Ordered:
d
d
3/3
1,891
1 891
297
847
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21
5
3/16
2,017
2 017
378
929
144
51
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Super Users at All Sites providing Support
Communication Sessions 2 times per day during Go-Live week
Compare 03/3/09, Visits for the Day: 1,936
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Numbers for Sept.
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Visit For the Day:
Labs Ordered:
Prescriptions:
Referrals to Specialists Ordered:
In-house
ouse Radiology
ad o ogy O
Ordered:
de ed
Telemedicine Services Ordered:
9/1
1,944
391
963
146
75
5
6
9/15
1,977
443
1 026
1,026
140
65
5
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Daily Total Visits* by Location
September 2010
2,100
2,000
1,970
1,900
,
2,004
1,901
1,800
1,860
2,007 1,999
1,861
1,776
1,698
1,700
1,934
1,768
1,649
Prod
ductivity
y
1,600
1,521
1,500
1,400
1,300
1,200
1,100
1 000
1,000
900
800
700
547
538
600
500
372
400
300
200
100
-
Wed Thurs
01 Pville
02 Ivnhoe
Fri
Sat
03 V Bridge
Mon
Tues
04 Wdlke
Wed Thurs
05 Spgvlle
06 C/O
Fri
Sat
07 ThRivrs
Mon
Tues
08 V Oak
Wed Thurs
09 Hnfrd
10 Gosh
Fri
Sat
11 Putnam
Mon
Series12
(*) Total Visits include Non-Billable Visits (Departments 710 Health Promotion and 320 Nutrition)
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Identified Staff Educational Gaps
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Comprehension of a need to change
QI Terms and Concepts
Change management techniques
Project management skills
Lean terms are confusing
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Identify and skill up staff embedded at each
of the locations
Align organizational behaviors
I
Introduce
d
additional
ddi i
l system iintegration
i
workshops
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Jay Kelley, CIO
jkelley@fhcn.org
Steven Palmer, MD, CMO
spalmer@fhcn.org
Norma Verduzco, Director of Operations Projects and Support Services
nverduzco@fhcn org
nverduzco@fhcn.org
Marisol de la Vega Cardoso, Director of QI
mdelavega@fhcn.org
g
g