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Ambulatory Health Care Facility of the Future: Integrating Lean Workflow Redesign and Lean Facility Design Principles

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As presented on March 19, 2010 at the 2010 AMGA Annual Conference

Presented by: Randall Huss, M.D., President, and Gerald Dowdy, VP Operations, St. John’s Clinic – Rolla Division; and Miguel Burbano de Lara, AIA, NCARB, Senior VP Healthcare, The Neenan Company

When faced with the opportunity of designing a new ambulatory facility to house a multi-specialty clinic practice, ASC and other outpatient services to be completed a year after implementation of their EHR, the St. John’s Clinic-Rolla team partnered with a progressive architectural team, The Neenan Company, to design and build a facility around the new electronic workflows. They integrated Lean workflow redesign and Lean facility design elements to achieve a facility capable of supporting the digital, paperless ambulatory practice of the future.

Published in: Health & Medicine
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Ambulatory Health Care Facility of the Future: Integrating Lean Workflow Redesign and Lean Facility Design Principles

  1. 1. ST. JOHN’S CLINIC<br />Rolla, Mo<br />ST. JOHN’S CLINIC<br />Rolla, Mo<br />
  2. 2. Ambulatory Health Care Facility of the Future:Integrating Lean Workflow Redesign and Lean Facility Design Principles<br />Randall Huss, MD, President <br />Gerald Dowdy, VP Operations<br />St. John’s Clinic-Rolla Division<br />Miguel Burbano, VP for Health Care<br />The Neenan Company<br />
  3. 3. What if . . . ?<br />What If . . . <br />Standard exam rooms<br />Greeting lobby with kiosk check-In<br />Immediateaccess to information<br />Servicesbrought to patient<br />Patient-centered comfort<br />Leverage capabilities of robust EHR<br />Fully digitalservices<br />Quietoffice<br />Teams of physicians and nurses<br />Improved communication<br />Sharedphysician lounges<br />
  4. 4. At lesscost!<br />Moreproviders<br />Morepoints of care<br />Moreservices<br />Morerevenue per square foot per provider<br /> . . . . In 14 months or less<br />
  5. 5. Opportunity<br />And<br />Challenge<br />
  6. 6.
  7. 7. What if . . . ?<br />The Future<br />Do more with same or less<br />Baby boomers surge<br />Integrated, coordinated care<br />Team-based care<br />Leverage technology<br />Chronic disease management<br />Multiple access points<br />Transparency and accountability<br />
  8. 8. Charge to Architects: Ambulatory Facility of the Future<br />
  9. 9. Strong, clear vision<br />Embrace economic challenges<br />Physician buy-in<br />Leadershipsupport<br />Teamapproach<br />Workflow redesign<br />Critical<br />Success<br />Factors<br />
  10. 10. Lean Principles<br />What if . . . ?<br />Lean Principles<br />Remove waste - eliminate non-value added work<br />Pursue perfection - zero defects<br />Workplace organizationandstandardization<br />“Just in time”inventory<br />Single piece flow; eliminatebatching<br />“Pull” vs. “push”<br />Continued pursuit of improvement<br />
  11. 11. US health care costs highest in the world<br />It is the access point to health care<br />Less technologicallycomplex; more logisticallycomplex<br />(compared to inpatient care)<br />The Mandate to Transform Ambulatory Care<br />
  12. 12. Obsolete Practices<br />The Mandate to Transform Ambulatory Care<br />Typical office workflow & designhave changed little in the last 50 years<br />American Ambulatory Care is still a cottage industry, uncoordinated and unaccountable<br />
  13. 13. Why transform Ambulatory Care?<br />
  14. 14. Greater opportunity to improve health of population<br />Frontline for preventive health care / wellness<br />Increase patient safety<br />Demand for patient–centered care<br />Patient–Centered Medical Home initiative<br />
  15. 15. Manage <br />Lean Principles<br />What if . . . ?<br />New Model of Care<br />Over 65population will double by 2030<br />Health care must support the increased demand<br />
  16. 16. Lean Principles<br />What if . . . ?<br />New Model of Care<br />Team-based care<br />Multiple points of access<br />Interactivetechnology<br />Chronic caremodel<br />Telemedicine and e-visits<br />Patient-Centered Medical Home<br />
  17. 17. Patient-centriccare<br />Leverage capabilities of robust EHR<br />Avoid paving the <br />“cow paths”<br />Why Redesign Workflows?<br />
  18. 18. Lean Principles<br />What if . . . ?<br />“It’s About Time . . .”<br />“The Patient-Centered, Physician Efficient Visit”<br />To focus on the patient’s experienceand expectations<br />To enhance the efficiencyand effectiveness of the physician<br />
  19. 19. Site visits<br />University of Utah <br />Community Clinics<br />“Learning Days”<br />Frequent provider meetings presenting Lean design opportunities<br />Earlyexecutive decision <br />for call center<br />Getting Started<br />
  20. 20. Physician & Co-Worker <br />Off-Site Retreat<br />Getting Started<br />Utah Leadership presented experience<br />St. John’s OPI Lean Team led group exercises<br />Physicians and co-workers challenged to apply workflow changes priorto Epic implementation<br />
  21. 21. Focus on patient experience<br />Right person / right job<br />Standardization<br />Lean facility design<br />Leverage and exploit technology<br />Effective communication<br />Core Principles<br />
  22. 22. Lean Clinic Workflow Redesign<br />
  23. 23. Manage <br />Lean Principles<br />What if . . . ?<br />The Patient Centered Physician Efficient Visit<br />The Goals<br /> Analysis of Ambulatory office visit process from patient’s perspective<br /> Optimize physician time and satisfaction<br />
  24. 24. Manage <br />Lean Principles<br />What if . . . ?<br />The Patient-Centered Physician Efficient Visit<br />Eliminate steps; avoid provider leaving the room<br />Eliminate all waste including non-value added work<br />Minimize patient movement<br />Standard workflows,room layout and supplies<br />Lean Process Improvement<br />
  25. 25. Manage <br />Lean Principles<br />What if . . . ?<br />The Patient-Centered Physician Efficient Visit<br />Implementation Strategies<br />Call center: centralized scheduling, registration, nurse triage, medication refills, Epic messaging<br />Monitor and manage call center metrics<br />Advanced access scheduling, minimal rules<br />Ultimately patient self-scheduling (Epic “My Chart”)<br />
  26. 26. Manage <br />Lean Principles<br />What if . . . ?<br />The Patient Centered Physician – Efficient Visit<br />Implementation Strategies<br />In-room scheduling and check-out<br />Patient has future appointments before leaving exam room<br />The Care Team model<br />
  27. 27. Manage <br />The Care Team Model<br />LPNs/MAs trained to <br />advanced competencies<br />Participate In Epic documentation<br />Off-load physician tasks <br />LPNs/MAs work as team; <br />not assigned to one provider<br />
  28. 28. Manage <br />The Care Team Model<br />Up-staffLPNs/MAs per provider<br />Provider and LPNs/MAs co-located<br />Only caregiversin the suite<br />
  29. 29. Manage <br />The Care Team Model<br />
  30. 30. Manage <br />Facility Design Considerations<br />Lean principles<br />Design for EHR workflows<br />Reception/check-in “kiosk” design<br />Minimize lobby area (“waiting” room)<br />Galleria concept for visitor comfort<br />
  31. 31. Manage <br />Facility Design Considerations<br />Care Team core located centrally in suite<br />Receptionist, check-out, and chart storage areas eliminated<br />Flexible interconnected business unit modules with “swing rooms”<br />Significantly reduced storage – Just in Time inventory<br />
  32. 32. Manage <br />Facility Design Considerations<br />Optimized space efficiencies within offices<br />Shared physician lounges over physician offices<br />Standard rooms; not assigned to only one provider<br />Allow minimum 3 rooms/provider in clinic<br />
  33. 33. Manage <br />Facility Design Considerations<br />Telemedicine room on each floor<br />Digital radiography with PACS; no wet processing<br />Pharmacy with drive-up<br />C.O.W. (“Calf”) and printer in each room<br />Community room doubles as group visit room<br />
  34. 34. Engagement, participation andcollaboration<br /> Led to acceptanceof Lean principles<br />Financial analysis of Lean design alternatives<br />Sealing the Deal<br />
  35. 35. SPACE – 13% Reduction<br />CAPACITY – 16% Increase<br />Lean Facility Design Results<br />
  36. 36. SPACE – 20% Reduction<br />CAPACITY – 16% Increase<br />Lean Facility Design Results<br />
  37. 37. Financial Savings<br />Lean Facility Design Results<br />Construction Cost<br /> $3,891,500<br />Annual Occupancy Cost<br /> $498,112<br />Annual Operation Cost<br /> $110,000 +/-<br />
  38. 38. Occupancy Cost<br />Lean Facility Design Results<br />Reduction in allocated occupancy cost to physicians<br />800-900 vs. 1300-1500<br />sq. ft. / physician<br />
  39. 39. Model for the Future<br />Model For future Ambulatory Care & facility design for <br />St. John’s Clinic and <br />Mercy Health System<br />Regional and national interest<br />
  40. 40. Operational Deployment and Challenges<br />
  41. 41. Manage <br />Operational Challenges<br />Epic EHR Go Live October 2008<br />Occupy new facility in September 2009<br />Fully Functioning EHR thus No Paper Charts<br />Implementation of Lean Design and Philosophy<br />Care Team Model <br />Call Center<br />Economic downturn<br />
  42. 42. Manage <br />Operational Challenges<br /> Widespread support for the EHR<br /> General agreement with Lean principles<br /> Resistance to change focused on the Care Team model and call center<br />
  43. 43. Manage <br />Preparation<br />Project team had multiple visits to University of Utah Community Clinics - “Learning Days” Program<br />Embrace skeptic thought and clinic leader<br />Attended additional educational seminars for Lean <br />Leadership attended Lean training<br />Pre Epic “Go Live” retreat<br />
  44. 44. Manage <br />Preparation / Call Center<br />Physician survey regarding expectations <br />Physician Champion<br />One on One physician meetings<br />Physician appointment schedule template<br />Protocol development<br />Scripting <br />
  45. 45. Manage <br />Implementation of <br />Call Center<br />Largest Rolla Family Medicine Business Unit - initial site for call center while implementing Lean workflow redesign focused on:<br /><ul><li>Improvement in Flow
  46. 46. Processes
  47. 47. Communication
  48. 48. Standardization
  49. 49. Just in Time Inventory</li></ul>Self-identified units added each week<br />
  50. 50. Manage <br />Critical Success Factors<br />Passionately follow the vision<br />Make data driven decisions<br />Plan and design for the regular 90% and manage to the 10% exceptions<br />Significantly reduce or eliminate appointment rules<br />
  51. 51. Manage <br />Critical Success Factors<br />Physician-led protocols for common messages<br /><ul><li>Prescription refills
  52. 52. Patient triaging
  53. 53. Test reporting / communicating</li></ul>When resistance occurs, ask why five times<br />Willingness to accept incremental improvement<br />
  54. 54. Manage <br />Overcoming Resistance<br />Lean Implementation<br />Improved efficiency<br />Lowertotal costs<br />Bestpractices <br />Communication<br />Physician champions<br />
  55. 55. Manage <br />Overcoming Resistance<br />The Care Team<br />Better overall care <br />More patient-centered<br />A team of “best” nurses rather “your” nurse<br />EHR enables Care Team model<br />Communication<br />Physician champion<br />
  56. 56. Manage <br />Overcoming Resistance<br />The Call Center<br />Allow clinical area to focus on care of the patient<br />Redesign the receptionist position<br />Key component of the Care Team concept<br />Noise reduction – minimal phone disruption<br />Expanded and consistentphone coverage <br />
  57. 57. Manage <br />Overcoming Resistance<br />The Call Center<br />Best practices model<br />Communication<br />Call center metrics<br />Physician champions and executive decision<br />
  58. 58. Manage <br />Lessons Learned<br />EHR is still not a paperless world - scanning challenge<br />Care Team challenge to function as a “team” in support of physician<br /><ul><li>Tendency to regress to traditional paper workflow and batching</li></ul>Begin EHR workflow redesign early<br />
  59. 59. Manage <br />Lessons Learned <br />Call Center<br />Unknown call volume<br />Schedulers vs. nursing staff<br />Staffing model for demand<br />Staff selection and competency <br />New digital technology – new processes<br /> Educating patients<br />“Call Center” label<br />
  60. 60. Design and FacilityImplementation<br />
  61. 61. Manage <br />The Magnitude of Change<br />How <br />BIG<br />is it ?<br />
  62. 62. Manage <br />Health Care Challenges<br />Constant change<br />Demanding<br />Continuous improvement & flexibility<br />
  63. 63. Manage <br />Health Care Challenges<br />Doing morewith less<br />
  64. 64. Disrupt status quo… <br />Thinking differently… <br />Seeing<br />differently…<br />
  65. 65. Reinvent<br /> your organization, your strategy, <br />your marketing, your image<br />
  66. 66. Reinvent<br /> your organization, your strategy, <br />your marketing, your image<br />
  67. 67. Continuous Improvement<br />Innovation<br />
  68. 68. These are extraordinary times which require extraordinarysolutions<br />
  69. 69. Manage <br />“Patient-Centered” Solutions<br />Pebble Project<br />Plane Tree<br />Lean<br />Six Sigma<br />Digital Simulations <br />EDAC<br />
  70. 70. Manage <br />Collaboration Trends<br />“Design thinking” is more than one discipline... <br />It requires interdisciplinary innovation <br />
  71. 71. Manage <br />Program at a Glance<br />
  72. 72. Manage <br />Site Plan<br />
  73. 73.
  74. 74.
  75. 75.
  76. 76. Manage <br />The Care Team Core<br />
  77. 77.
  78. 78. Manage <br />The Galleria Lobby<br />Patient-Centered <br />Environments<br />
  79. 79. Manage <br />The Galleria Lobby<br />
  80. 80. Manage <br />The Galleria Lobby<br />
  81. 81. Manage <br />The EHR Enabled Exam<br />
  82. 82. Manage <br />The Digitally Enabled OR<br />
  83. 83. Manage <br />Shared Physician Lounge<br />
  84. 84. Manage <br />The Care Team Core<br />
  85. 85.
  86. 86. And just in case you think this project consumed the entirety of the past two years…<br />
  87. 87.
  88. 88. QUESTIONS?<br />Dr. Randall Huss: Randall.Huss@Mercy.Net<br />Gerald Dowdy: Gerald.Dowdy@Mercy.Net<br />Miguel Burbano de Lara: miguel.burbano@neenan.com<br />

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