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Lean Process Improvement In Outpatient Clinics
- 1. Lean Process Improvementin Outpatient Clinics Decision Sciences Institute Annual Meeting New Orleans, Louisiana – November 15, 2009 Linda LaGanga, Ph.D. Director of Quality Systems & Operational Excellence Mental Health Center of Denver Denver, CO, USA Additional information available at: http://www.outcomesmhcd.com/Pubs.htm http://Leeds.colorado.edu/ApptSched © 2009 – Linda LaGanga 1 DSI 2009 – New Orleans © 2008 – Linda LaGanga and Stephen Lawrence 2009
- 2. Agenda 1. Background on the Organization 2. Lean Approaches 3. The Lean Improvement Projects 4. Insights and Recommendations 5. Contributions and Future Directions 2 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 3. 1. Background on the Organization 3 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 4. The Mental HealthCenter of Denver (MHCD) is a private, not-for-profit, 501 (c) (3), community mental health care organization Providing comprehensive, recovery-focused services to more than 11,500 residents in the Denver metro area each year. Founded in 1989, MHCD is Colorado’s leading provider and key health care partner in the delivery of outcomes- based mental health services. “Enriching lives and minds by focusing on strengths and recovery.” 4 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 5. MHCD Recent InnovationAwards Effective Programs The U.S Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA) Science to Service Award 2009 GROW (Growth and Recovery Opportunities for Women) program. Evidence-based interventions shown to prevent and/or treat mental illnesses and substance abuse. Read more at http://www.samhsa.gov/scienceandservice/cod2009.aspx. Efficient Systems Our Lean Process Improvement in Outpatient Healthcare Project won recognition of the Colorado Behavioral Healthcare Council (CBHC) and received the 2009 Golden Abacus Award for Best practices in the Non-Clinical Arena www.cbhc.org. Environment Leadership MHCD and its Together Green Team were nominated by the Governor’s Energy Office for a Colorado Environmental Leadership Program and were named a Bronze Award winner for its commitment to environmental leadership. Visit http://www.cdphe.state.co.us/oeis/elp/index.html Awards based on measurable results and outcomes Services, Evaluation & Research, Quality & Operational Excellence 5 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 6. Healthcare: Research and Operational Excellence Accountability Tracking and data availability Outcomes Quality management Efficiency Effectiveness Evidence-based practices 6 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 7. Research Capacity Clinical and Rehabilitation Service Effectiveness Quality Systems & Operational Excellence Ph.D. Staff: 4 + 1 Ph.D. Candidate OR, Statistics, Psychology Master-level Licensed / Certified Clinicians Evaluation & Research Team Sponsor and analysis of Lean Process Improvement Action Research 7 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 8. Action Research “Researchin action, rather than research about action; participative; concurrent with action; a sequence of events and an approach to problem solving.” (Coughlan and Coghlan, 2002) Field study situation in which there was active communicating with practitioners, reporters, and the public in response to the initial study (LaGanga and Lawrence, 2007 & 2008) Concurrently applying the emerging recommendations and insights to a real change process -- the lean process improvement program The author was a direct sponsor and active participant in solving an operational problem and effecting change in an actual organization 8 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 9. 2. Lean Approaches 9 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 10. Motivation Healthcare Capacity Funding restrictions Demand exceeds supply Serve more people with limited resources Manufacturing Scheduling Resource utilization Maximize throughput Healthcare Scheduling as the point of access Maximize appointment yield 10 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 11. 2007 Consumer Reportssurvey of 39,000 patients and 335 primary care doctors (Hitti, 2007) Top patient complaint was about time spent in the waiting room (24% of patients) Followed by 19% of patients who complained that they couldn’t get an appointment within a week Fifty-nine percent of doctors in the survey complained that patients did not follow prescribed treatment and 41% complained that patients waited too long to schedule appointments. 11 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 12. Literature: Access toHealthcare Institute of Medicine (2001) Crossing the quality chasm: A new health system for the 21st century. Murray & Berwick (2003) Advanced access: Reducing waiting and delays in primary care. Journal of the American Medical Association, 289(8). Green, Savin, & Murray (2007) Providing timely access to care: What is the right patient panel size? The Joint Commission Journal on Quality and Patient Safety, 33(4). 12 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 13. Lean Approaches Reducing Waste Underutilization Overtime No-shows Patient Wait time Customer Service Choice Service Quality Outcomes 13 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 14. Lean Process Improvementin Healthcare Documented success in hospitals ThedaCare, Wisconsin Prairie Lakes, South Dakota Virginia Mason, Seattle University of Pittsburgh Medical Center Denver Health Medical Center Influences Toyota Production System Ritz Carleton Disney Hospitals to Outpatient Clinics run by hospitals Collaborating outpatient systems 14 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 15. 3. Lean Projects Lean Process Facilitator and Sponsor at 15 DSI 2009 – New Orleans Lean Program Exhibit Booth, October, 2009© 2008 – Linda LaGanga 2009
- 16. Field Work: Interviews Lean Event Process at the Mental Health Center of Denver 11/14/2009 Kovach & Fredendall - DSI 16 16 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 17. Lean Projects Overview Rapid Improvement Capacity Expansion Express Intake Human Resources Hiring Process Grants Financial Management New Clinician Training 17 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 18. First Lean Project Rapid Improvement Capacity Expansion (RICE) Team January, 2008 18 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 19. 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 (avoidance): $90,000 - $100,000 for staffing and space 19 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 20. Lean Process Improvement: RICE Project System Transformation Appointments Scheduled and No-Show Rates 450 20% 400 Appointments 350 15% 300 250 10% 200 150 100 5% 50 0 0% Mon Tue Wed Thu Fri Mon Tue Wed Thu Fri Year Before Year After Lean Improvement Lean Improvement Appointments No-Show Rate 20 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 21. How was thisshift accomplished? Day of the week: shifted and added Tuesdays and Thursdays Welcome call the day before Transportation and other information Consolidated steps Orientation to Intake Assessment Eliminated an opportunity for no-show Group intakes Overbooking Flexible capacity 21 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 22. Lean Scheduling Challenge Choice versus Certainty Variability versus Predictability Sources of Uncertainty / Variability No-shows Service duration Customer (patients’) Demand Time is a significant factor Airline booking models? 22 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 23. Second Lean Project Express Intake Team August, 2008 23 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 24. Motivation for FastTrack Intake More rapid access to targeted populations Special grants and contract funding No state CCAR needed 7 pages 25 outcome domains Scarcity of intake appointment slots Lengthy intake process Average 2.07 hours Many forms 17 for adults 19 for children/adolescents 24 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 25. Current State (BeforeLean Event) Approximately 2/3 seeking services turned away If admitted, up to two week wait for intake appointment All slots filled early in the week Three or more staff required Access center clinical / call taker MIS staff Intake clinician 25 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 26. Target State Provide high-quality services Provide access to more people seeking services Start service delivery promptly Match work time to reimbursement rate Positive consumer experience Valuable clinical outcomes 26 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 27. Gaps Treatment delays Perception that center is not accessible Inadequate reimbursement Redundant data collection Unnecessary work and data collection Errors in recording and processing data 27 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 28. Solutions Identify appropriate payer/contract sources Identify value-added intake information Reduced data items/forms from 17 (or 19) to 4 No state CCAR outcome form Focus on appropriate outcome measures 28 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 29. Solutions Bypass Access Team Direct to designated clinicians Continuity of care Contact & Triage form Halved from 4 to 2 pages Completed by clinicians Eliminate waiting for MIS staff to complete form Use for all new intakes, not just special grants and contracts 29 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 30. Electronic Health Record Opportunities to streamline clinical work flow Improve quality of care Structures and standardizes work processes Menus Programmed logic and forms Data validation and feedback Lean Paradox Bottleneck in programming Implementation delays in some projects New forms and intake processes within 90 days 30 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 31. Results with Departmentof Corrections Prison parolees Rate of intakes tripled Duration appeared unchanged Standard versus actual time recorded 3 hours > 2.07 average of other clinicians 31 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 32. Lean Process Improvement:(First 3 months) Express Intake: Fast Track Project Clinician Time to do Intake 70% 60% 50% Cases 40% 30% 20% 10% 0% 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 Before Fast Track Hours After Fast Track 32 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 33. Summary of Results In the first three months of operation, the average service time decreased from 2.06 to 1.98 hours Effect small but significant (p < .05). More encouraging is the change in the distribution of service time, Percentage of total intakes that were completed within two hours increased from 67.5% to 75% so the percentage of intakes exceeding two hours decreased from 32.5% to 25%. 33 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 34. Results Service times shortening Decreased range and variability Room for more intakes Increased access to services 34 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 35. Other Efficiencies Elimination of “Hidden factory” of MIS Not captured in EHR system Data entry Checking and correcting clinician errors Not visible in productivity measures More profitable enrollment Ensure correct billing to appropriate payers Appropriate outcome measures 35 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 36. Third Lean Project Human Resources Hiring Project October, 2008 36 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 37. Hiring: Improving aBusiness Process Delays and bottlenecks in communication Automated communication Built on Electronic Health Record Required systems analysis and programming Six months to implement Reduced time to fill positions by 3 days Harder to measure than clinical improvement 37 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 38. Fourth Lean Project Grants Financial Management Team December, 2008 38 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 39. Financial Management: A Business Process Initial state: Lack of feedback and reporting Requires technology and programming About a year to implement Dependent on completion of prior lean project for staff tracking and allocation 39 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 40. Fifth Lean Project New Clinician Training Team January, 2009 40 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 41. New Clinician Training: A Business Process Target State: Clinicians trained to be productive within 3 days of hire Job requires use of Electronic Health Record Quickly determined how to achieve target Designed new training program Implemented initial computer training within 1 month Development of on-line training modules: Little progress due to other staff commitments 41 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 42. 4. Insights andRecommendations 42 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 43. The Right People Talents Credibility Stakeholders Ownership Motivation “People are our product” What’s in it for me? “Why am I being punished?” “Can I come back tomorrow, too?” 43 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 44. The Right Problems The first project was a perfect fit Immediate change Energized and committed participants Technology was valuable for measurement Didn’t require reprogramming EHR Success fueled interest Not everything could or should be a lean project Lean paradox Bottlenecks Rapid improvement: Not! 44 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 45. The Lean Paradox: Projects by Functional Area Electronic Health Record Programming and Enhancements 45 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 46. Project Management and Organizational Discipline Assigning ownership and follow-through Critical mass Project management systems Selective about lean projects Improving measurement processes Working on financial analysis 46 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 47. 7. Contributions & Future Directions 47 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 48. Contributions Outpatient services crucial to cost-effective healthcare delivery Lots of hospital research but little in outpatient Lean can greatly expand direct service capacity Room to leverage lean outpatient business process improvement 48 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 49. Future Work Ongoing analysis and improvement of lean approaches Continued action research on Quality Improvement in outpatient settings Lean Learning Collaborative Find other outpatient organization using lean Gather and share ideas through on-line group Lean Leaders and Catalysts for Improvement on LinkedIn 49 DSI 2009 – New Orleans © 2008 – Linda LaGanga 2009
- 50. Questions? Comments? Discussion? Lean Process Improvement in Outpatient Clinics Decision Sciences Institute Annual Meeting New Orleans, Louisiana – November 15, 2009 Linda LaGanga, Ph.D. Director of Quality Systems & Operational Excellence Mental Health Center of Denver Denver, CO, USA Additional information available at: http://www.outcomesmhcd.com/pubs/publications.htm http://Leeds.colorado.edu/ApptSched 50 DSI 2009 – New Orleans © 2008 – Linda LaGanga and Stephen Lawrence 2009