Transformation of a Service Operations           System through Lean Process            Improvement and Learning          ...
What’s this Action Research about?• Healthcare Service Operations Systems      – Configure      – Deliver      – Measure  ...
Research in Improving Outpatient                      Healthcare Operations                  Capacity Expansion           ...
The 2‐Dimensional Continuum of Healthcare                                              Physical Health  Inpatient Services...
First Healthcare Delivery Organization              Wins Shingo Prize in 2011• Denver Health wins  for Lean Systems Improv...
Lean Transition to Outpatient Settings   • Hospitals to Outpatient         – Clinics run by hospitals         – Collaborat...
Language and Values      • Applying manufacturing principle to health         and human services      • “Our product is pe...
Value: Enhance Funding                            and Treatment Outcomes     • Healthcare Funding     • Process Measures  ...
Stretch Your Dollar               $ The Mental Health Center of Denver admitted               400 new adults with serious ...
Court to Community Treatment Outcomes         •       After 18 months:         •       2/3 Have Not Been Re‐Arrested      ...
Reaching Recovery, © 2011Behavioral Operations -2011, © Linda LaGanga, 2011
Example of a Lean Improvement Project                 and the Continuum of Care  • Coordinated and Integrated Healthcare S...
Measures and Sources                   • Claims data                       – Hospital admission rates                     ...
Key Lean Project   • Timeliness In Access to Care   • Rapid Improvement Capacity Expansion (RICE)       – Concentrated on ...
Configuration of Appointment Allocation System                              Supplier                                      ...
Intake Process: Before Lean Improvement Consumers                                          Providers                   Ori...
Intake Process: After Lean Improvement        Consumers                                                          Providers...
Intake Process                                         Before and After                                                   ...
Appointments scheduled and no‐show rates               before and after lean improvement                                  ...
Lean Process Improvement: One Year After               Rapid Improvement Capacity Expansion                            RIC...
Improvement in accessibility and timely access to services         based on service value in lean outpatient health care  ...
Improvement in accessibility and timely access to                 services after Lean Improvement  Consumer’s steps and ti...
Comparing process steps:                                   Before and After  • Before:        • Total steps with recurrent...
Comparing process time and lag time: • Before:        • Total time (minimum possible) = (30+50+60 minutes) + 2 days       ...
Process Improvement    • Accomplished by involving clinicians and consumers    • Reconfiguration for timely and consumer‐f...
What is the                          Lean Paradox?   • Just‐in‐time?      – NO   • New Bottlenecks?      – YES   • Rapid I...
Transformation of a Service Operations                     System through Lean Process                       Improvement a...
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Transformation of a Service Operations System through Lean Process Improvement

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Transformation of a Service Operations System through Lean Process Improvement and Learning Collaboration. Presentation at Behavioral Operations Management Conference. INSEAD Business School, Fontainebleau, France, June, 2011.

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Transformation of a Service Operations System through Lean Process Improvement

  1. 1. Transformation of a Service Operations  System through Lean Process  Improvement and Learning  Collaboration Behavioral Operations Management Conference, INSEAD Business School,Fontainebleau, France, June, 2011 Linda LaGanga, Ph.D., LPC Director of Quality Systems & Operational Excellence Mental Health Center of Denver Denver, CO, USA Linda.Laganga@mhcd.orgAdditional information available at:https://secure.smhcd.org/OutcomesPubs.aspxBehavioral Operations -2011, © Linda LaGanga, 2011 1
  2. 2. What’s this Action Research about?• Healthcare Service Operations Systems – Configure – Deliver – Measure – Improve• The Continuum of Healthcare• Lean Transformation and Learning  Collaboration  in Inpatient to Outpatient Settings• Timeliness in Access to Care• The Lean ParadoxBehavioral Operations -2011, © Linda LaGanga, 2011
  3. 3. Research in Improving Outpatient  Healthcare Operations Capacity Expansion Process Improvement Appointment  Lean Process  CQI Scheduling ImprovementDecision utility model, Action research, Interviews andTo overbook or not Empirical case study pilot surveysLaGanga & Lawrence LaGanga Kovach,(2007, DSJ) (2011, JOM) Fredendall, Presentation Objective:   LaGanga)• Position Action Research with several  (2011, DSI) methodologies & philosophies• Consider areas of research interest in Behavioral  Ops ManagementBehavioral Operations -2011, © Linda LaGanga, 2011 3
  4. 4. The 2‐Dimensional Continuum of Healthcare Physical Health Inpatient Services / Emergency Department Outpatient Services Mental Health / Behavioral HealthBehavioral Operations -2011, © Linda LaGanga, 2011 4
  5. 5. First Healthcare Delivery Organization  Wins Shingo Prize in 2011• Denver Health wins for Lean Systems Improvement• Denver Health executives estimate the program  saved $88 million in operational expenses • Helped safeguard all 5,500 Denver Health jobs. • Even in a poor economy, didn’t have to cut care for  the citys uninsured and underserved.• Auge, Denver Post, 3/23/11, “Denver Health Wins  International Award for Efficiency.”Behavioral Operations -2011, © Linda LaGanga, 2011 5
  6. 6. Lean Transition to Outpatient Settings • Hospitals to Outpatient – Clinics run by hospitals – Collaborating outpatient systems • Outpatient Community Mental Health Center – Expand Access – Reduce Process times – Streamline documentation – Coordinate care – Improve treatment planning – Enhance fundingBehavioral Operations -2011, © Linda LaGanga, 2011 6
  7. 7. Language and Values • Applying manufacturing principle to health  and human services • “Our product is people” • Measure and report what people understand  and value • Productivity  • “Consumer Service Hours”Behavioral Operations -2011, © Linda LaGanga, 2011 7
  8. 8. Value: Enhance Funding  and Treatment Outcomes • Healthcare Funding • Process Measures  – Counting – Compliance • Service Effectiveness – Outcomes Measures – Throughput to serve more people – Community impact – Cost effectivenessBehavioral Operations -2011, © Linda LaGanga, 2011 8
  9. 9. Stretch Your Dollar    $ The Mental Health Center of Denver admitted  400 new adults with serious mental illness into high  intensity services the first year of implementation of  its Recovery Needs Level instrument with no  additional resources. $ Based on a cost of $12,500 per consumer  = Total public cost saving annually is $5 Million.  Reaching Recovery, © 2011Behavioral Operations -2011, © Linda LaGanga, 2011
  10. 10. Court to Community Treatment Outcomes • After 18 months: • 2/3 Have Not Been Re‐Arrested • 80% Reduction in Jail Time • $104,790 Savings to Taxpayers Change in # of Jail Days: All Clients 2000 N =1873 1600 # Jail Days 1200 80% Reduction 800 N = 376 400 0 Pre Post Admission PeriodBehavioral Operations -2011, © Linda LaGanga, 2011 10
  11. 11. Reaching Recovery, © 2011Behavioral Operations -2011, © Linda LaGanga, 2011
  12. 12. Example of a Lean Improvement Project  and the Continuum of Care • Coordinated and Integrated Healthcare Services • Motivation for Lean Improvement :  Reduce Emergency Room and inpatient use in Behavioral  Health Setting  • Goals:  – 25% reduction of Medicaid‐funded inpatient costs for Behavioral  Healthcare for calendar year 2010  – Increased collaboration between inpatient and outpatient  providers.  – Increased financial resources for outpatient services.  – Availability of correct level of service when neededBehavioral Operations -2011, © Linda LaGanga, 2011 12
  13. 13. Measures and Sources • Claims data  – Hospital admission rates – Average length of stay – Emergency Room utilization – Hospital recidivism – Follow‐up rates after discharge • External benchmarking against other managed care  organizations • Outpatient admissions  – Call center data – Electronic Medical Record – Service Requests – Admissions – Time to appointments – Show ratesBehavioral Operations -2011, © Linda LaGanga, 2011 13
  14. 14. Key Lean Project • Timeliness In Access to Care • Rapid Improvement Capacity Expansion (RICE)  – Concentrated on Appointment Allocation/Assignment Process – Shifting and increasing appointment availability – Increasing Show Rate – Matching interactions to consumer needs • LaGanga, 2011. Lean Service Operations:  Reflections and New Directions for Capacity Expansion  in Outpatient Clinics.  Journal of Operations Management 29(5). • Research started as appointment scheduling models for no‐shows  and overbooking; evolved to lean focus.Behavioral Operations -2011, © Linda LaGanga, 2011 14
  15. 15. Configuration of Appointment Allocation System Supplier Customer Access Center Clinical Intake Teams Consumers Seeking Access Check appointment Receive call inventory for from consumer availability Consumer not admitted. Exits but Release appointments to may call days of the scheduling week again. Monday No slots available or no appropriate match for consumer Inventory ofTuesday Appointments Wednesday Consumer given an Intake Consumer Match consumer appointment. exits, waits to appointment slot and for Thursday remove appointment Intake from inventory appointment. of available appointments FridayBehavioral Operations -2011, © Linda LaGanga, 2011 15
  16. 16. Intake Process: Before Lean Improvement Consumers Providers Orientation Orientation Orientation Orientation Idle Intake Clinician due to consumer no-show Delay (Days) Consumer leaves and doesn’t return Individual Intake Individual Assessment Intake Individual Assessment Intake Assessment Idle Intake Clinician due to consumer no-show Delay (Days) Consumer leaves and doesn’t return Individual Psychiatric Individual Evaluation Psychiatric Evaluation Idle Psychiatrists due to consumer no- shows Exit: Completed IntakesBehavioral Operations -2011, © Linda LaGanga, 2011 16
  17. 17. Intake Process: After Lean Improvement Consumers Providers Orientation Overbooked consumer who shows up Individual Intake Individual Assessment Intake Individual Assessment Intake Individual Assessment Intake Assessment Clinician called into service for overbooked consumer who showed upBehavioral Operations -2011, © Linda LaGanga, 2011 17
  18. 18. Intake Process Before and After  Consumers Providers Consumers Providers Orientatio n Orientati Orientatio n Orientatio on n Orientatio n Idle Intake Clinician due to Overbooked consumer no- consumer who show shows up Individu Delay Consumer (Days) alIndividu leaves and doesn’t return Intake alIndividu al Individua Assess Intake Individual mentl Assess Intake Intake Individual Intake Clinician called into ment Assess Assessme Intake Individual Assess service for ment ntAssessme Intake ment overbooked ntAssessme consumer who nt showed up Idle Intake Clinician due to consumer no- show Delay Consumer (Days) leaves and doesn’t return Individual Psychiatri Individual c Psychiatri Evaluation c Evaluation Idle Psychiatrists due to consumer no-shows Exit: Completed IntakesBehavioral Operations -2011, © Linda LaGanga, 2011 18
  19. 19. Appointments scheduled and no‐show rates  before and after lean improvement Before Appointments Scheduled After 500 400 300 200 100 0 Mon Tue Wed Thu Fri Before No-Show Rates After 20% 15% 10% 5% 0% Mon Tue Wed Thu FriBehavioral Operations -2011, © Linda LaGanga, 2011
  20. 20. Lean Process Improvement: One Year After Rapid Improvement Capacity Expansion RICE Results • Analysis of the1,726 intake appointments for the one year  before and the full year after the lean project  • 27% increase in service capacity – from 703 to 890 kept appointments) to intake new consumers • 12% reduction in the no‐show rate – from 14% to 2% no‐show • Capacity increase of 187 additional people who were  able to access needed services, without increasing staff or other expenses for these  services • 93 fewer no‐shows for intake appointments during the first full year of  RICE improved operations.  • Annual cost savings (expense avoidance): $90,000 ‐ $100,000 for staffing and spaceBehavioral Operations -2011, © Linda LaGanga, 2011 20
  21. 21. Improvement in accessibility and timely access to services based on service value in lean outpatient health care (based on Womack and Jones, 2005). Before Time Step likely to recur? Consumer’s steps and time for admission to services, before lean process improvement. 1.  Call Access Center for admission to services. 10 minutes Yes 2.  No slot available.  Wait to call again.  3 days ‐1 week Yes 3.  Call Access Center for admission to services. 10 minutes Yes 4.  Possible slot available.  Provide more assessment information. 15 minutes Yes 5.  No appropriate slot available.  Wait to call again. 3 days ‐1 week Yes 6.  Call Access Center for admission to services.  Provide more assessment information.   30 minutes. No Appropriate slot obtained. Appointments made for orientation and intake assessment. 7.  Wait for orientation. 1 – 7 days. No 8.  Orientation for paperwork, explanation of policies and procedures. 50 minutes No 9.  Wait for Intake Assessment session. 1 – 7 days. No 10.  Intake Assessment session with individual clinician. 60‐90 minutes. No Total time (minimum possible) 2 days + 140  minutes Total time (maximum if consumer is admitted on 4th call) 5 weeks 245  minutes  Actual clinical service time (value‐creating time) 60‐90 minutes Total steps with recurrent steps Behavioral Operations -2011, © Linda LaGanga, 2011 14
  22. 22. Improvement in accessibility and timely access to services after Lean Improvement Consumer’s steps and time for admission to services, after  Time Step likely to recur? lean process improvement. 1. Call Access Center for admission to services. 10 minutes Yes 2. No slot available. Wait to call again. 1 – 3 days Yes 3. Call Access Center for admission to services. 10 minutes Yes 4. Possible slot available. Provide more assessment information. 15 minutes Yes 5. No appropriate slot available. Wait to call again. 1 – 3 days Yes 6. Call Access Center for admission to services. Provide more assessment information. 30 minutes. No Appropriate slot obtained. Appointment made for orientation and sequential intake assessment. 7. Wait for Intake clinician to call and welcome. 1-3 days No 8. Talk to Intake clinician about appointment. 10 minutes No 7. Wait for orientation. 1 day No 8. Group Orientation for paperwork, explanation of policies and procedures. 40 minutes No 10. Intake Assessment session with individual clinician. 60-90 minutes. No Total time (minimum possible) 2 days + 140 minutes Total time (maximum if consumer is admitted on 3rd call) 1 week + 190 minutes Actual clinical service time (value-creating time) 70-100 minutesBehavioral Operations -2011, © Linda LaGanga, 2011 Total steps with recurrent steps POMS-2011, Linda 12 ©22
  23. 23. Comparing process steps: Before and After • Before: • Total steps with recurrent steps (worst case with  3 instances of steps 4 and 5) = 3 x 3 + 5 = 14 • After • Total steps with recurrent steps (worst case  with 2 instances of steps 4 and 5) =  2 x 3 + 6 = 12 • Eliminates 2 stepsBehavioral Operations -2011, © Linda LaGanga, 2011
  24. 24. Comparing process time and lag time: • Before:  • Total time (minimum possible) = (30+50+60 minutes) + 2 days  = 2 days 2 hours and 20 minutes • Total time (maximum if consumer is admitted on 4th call)  • = 5 weeks 4 hours and 5 minutes • After: • Total time (minimum possible) = Same as above • Total time (maximum if consumer is admitted on 3rd call)  • = 1 week 3 hours and 10 minutes • Process and lag time reduction of worst case: • > 4 weeksBehavioral Operations -2011, © Linda LaGanga, 2011
  25. 25. Process Improvement • Accomplished by involving clinicians and consumers • Reconfiguration for timely and consumer‐friendly  access • Measured – Increased intakes – Decreased no‐show rates – Decreased delays to access • Multi‐dimensional impacts (projections) – Reduced inpatient expenses – Physical/Behavioral dimensions of healthcare • Transition • TransformationBehavioral Operations -2011, © Linda LaGanga, 2011
  26. 26. What is the  Lean Paradox? • Just‐in‐time? – NO • New Bottlenecks? – YES • Rapid Improvement? – NOT! • Solutions – Clear out project clutter – Prioritize – Realign project  scheduling • Sustainability and  human behaviorBehavioral Operations -2011, © Linda LaGanga, 2011 26
  27. 27. Transformation of a Service Operations  System through Lean Process  Improvement and Learning  Questions? Collaboration Comments? Behavioral Operations Management Conference, INSEAD Business School, Fontainebleau, France, June, 2011 Linda LaGanga, Ph.D. Director of Quality Systems & Operational Excellence Mental Health Center of Denver Denver, CO, USA Linda.Laganga@mhcd.orgAdditional information available at:https://secure.smhcd.org/OutcomesPubs.aspxBehavioral Operations -2011, © Linda LaGanga, 2011 27

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