Transformation of a Service Operations System through Lean Process Improvement

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.org
Additional information available at:
https://secure.smhcd.org/OutcomesPubs.aspx
Behavioral Operations -2011, © Linda LaGanga, 2011 1

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 Paradox
Behavioral Operations -2011, © Linda LaGanga, 2011

Research in Improving Outpatient
Healthcare Operations
Capacity Expansion Process Improvement

Appointment Lean Process
CQI
Scheduling Improvement
Decision utility model, Action research, Interviews and
To overbook or not Empirical case study pilot surveys
LaGanga & 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 Management

The 2‐Dimensional Continuum of Healthcare

Physical Health

Inpatient Services / Emergency Department Outpatient Services

Mental Health / Behavioral Health


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 city's uninsured and underserved.
• Auge, Denver Post, 3/23/11, “Denver Health Wins
International Award for Efficiency.”

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 funding


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”


Value: Enhance Funding
and Treatment Outcomes
• Healthcare Funding
• Process Measures
– Counting
– Compliance
• Service Effectiveness
– Outcomes Measures
– Throughput to serve more people
– Community impact
– Cost effectiveness


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, © 2011

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 Period

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 needed


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 rates

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.


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

Friday

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 Intakes


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 up


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
Intakes


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 Fri


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 space

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
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

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.

2. No slot available. Wait to call again. 1 – 3 days 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 minutes
Total steps with recurrent steps POMS-2011, Linda 12 ©22

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 steps


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 weeks


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
• Transformation

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 behavior

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.org
Additional information available at:
https://secure.smhcd.org/OutcomesPubs.aspx

Transformation of a Service Operations System through Lean Process Improvement

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