applying the theory of constraints
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Applying theTheory of Constraints
to Ambulatory Practice
Applying theTheory of Constraints
to Ambulatory Practice
A Pathway to Efficiency and Quality
Peter B. Anderson, MDCharles O. Frazier, MD
• Where we are today in family medicine.
• How did we get here?
• Where would we like to be in family medicine?
• What changes can we make to go from where we are to where we want to be?
• Where we are today in family medicine.
• How did we get here?
• Where would we like to be in family medicine?
• What changes can we make to go from where we are to where we want to be?
Family MedicineFamily Medicine
Point B:
Where we would like to be in
family medicine.
Point B:
Where we would like to be in
family medicine.
Point A:
Where we are today in family
medicine.
How did we get here?
Point A:
Where we are today in family
medicine.
How did we get here?
What changes can we make?
Family MedicineFamily Medicine
Where are we today?Where are we today?• 60% of PCP’s would leave primary care if they could.• The number of US medical students choosing primary care has
declined 10 years in a row – totaling a 50% drop.• 27% of PCP’s report symptoms of being burnt-out.• 50% of PCP’s describe their office as “chaotic.”• “We’re working harder and harder, but not earning an
increasing level of income.” – Medical Economics 12/2007• “How do we leverage our data and quality and get...Medicare
not to make pay cuts that are going to all but destroy primary care.” – Medical Economics 12/2007
• “Crisis in Health Care” – Medical Economics 12/2006
Conclusion: Point A is not looking too good…
• 60% of PCP’s would leave primary care if they could.• The number of US medical students choosing primary care has
declined 10 years in a row – totaling a 50% drop.• 27% of PCP’s report symptoms of being burnt-out.• 50% of PCP’s describe their office as “chaotic.”• “We’re working harder and harder, but not earning an
increasing level of income.” – Medical Economics 12/2007• “How do we leverage our data and quality and get...Medicare
not to make pay cuts that are going to all but destroy primary care.” – Medical Economics 12/2007
• “Crisis in Health Care” – Medical Economics 12/2006
Conclusion: Point A is not looking too good…
Point B:
Where we would like to be in
family medicine.
Point B:
Where we would like to be in
family medicine.
Point A:
Where we are today in family
medicine.
How did we get here?
Point A:
Where we are today in family
medicine.
How did we get here?
What changes can we make?
Family MedicineFamily Medicine
How did we get here?How did we get here?
Traditional Office Visit
Traditional Office Visit
House CallHouse CallModern Medicine 1920’s – 1950’s
??Traditional Office Visit
Traditional Office Visit
Managed Care 1990’s
Point B:
Where we would like to be in
family medicine.
Point B:
Where we would like to be in
family medicine.
Point A:
Where we are today in family
medicine.
How did we get here?
Point A:
Where we are today in family
medicine.
How did we get here?
What changes can we make?
Family MedicineFamily Medicine
Where would we like to be in family medicine?Where would we like to be in family medicine?
• Evidence-based, quality care
• High patient satisfaction
• High staff satisfaction
• Comparable salary and work week
• Sufficient free time
• Evidence-based, quality care
• High patient satisfaction
• High staff satisfaction
• Comparable salary and work week
• Sufficient free time
Point B:
Where we would like to be in
family medicine.
Point B:
Where we would like to be in
family medicine.
Point A:
Where we are today in family
medicine.
How did we get here?
Point A:
Where we are today in family
medicine.
How did we get here?
What changes can we make?
Family MedicineFamily Medicine
Life is short, and Art long; the crisis fleeting;
experience perilous, and decision difficult.
Hippocrates 400B.C.
Life is short, and Art long; the crisis fleeting;
experience perilous, and decision difficult.
Hippocrates 400B.C.
Baby Boomers are AgingBaby Boomers are Aging
• 34 Million > 65 years old in 2007
• 70 Million > 65 years old in 2030
• 34 Million > 65 years old in 2007
• 70 Million > 65 years old in 2030
More Patients, Less DoctorsMore Patients, Less Doctors
WE ARE BOOMERS TOO !Numbers of Physicians over 55WE ARE BOOMERS TOO !Numbers of Physicians over 55
0
50,000
100,000
150,000
200,000
250,000
300,000
1985 2005
1985
2005
0
50,000
100,000
150,000
200,000
250,000
300,000
1985 2005
1985
2005
• More and Older Patients
• Higher Disease Burden
• Higher Expectations both Patient and Regulatory
• Short Run Fewer and Older Physicians
• More and Older Patients
• Higher Disease Burden
• Higher Expectations both Patient and Regulatory
• Short Run Fewer and Older Physicians
In SummaryIn Summary
I always tried to turn every disaster into an opportunity.
John D. Rockefeller
Paradigm ShiftParadigm Shift
Care will be delivered in different ways than it has been done for the last 100 years.
Care will be delivered in different ways than it has been done for the last 100 years.
What changes can we make?What changes can we make?• Extended Hours• Open Access Schedule• Non-Physician Providers• Micro Practice• Concierge Practice• Ancillary Services:
1. Cosmetic Procedures2. Day Spa Services3. Laser Hair Removal4. Weight Reduction
Programs5. Obese Children
Programs6. Health Fitness
Nutritional Program• Technology Advances:
1. EMR2. Practice Web Portals3. Patient Interviewing
Software4. Online Visits
• Group Visits• Family Team Care
• Extended Hours• Open Access Schedule• Non-Physician Providers• Micro Practice• Concierge Practice• Ancillary Services:
1. Cosmetic Procedures2. Day Spa Services3. Laser Hair Removal4. Weight Reduction
Programs5. Obese Children
Programs6. Health Fitness
Nutritional Program• Technology Advances:
1. EMR2. Practice Web Portals3. Patient Interviewing
Software4. Online Visits
• Group Visits• Family Team Care
Traditional Office Visit
Traditional Office Visit
Managed Care 1990’s
• AvailabilityAvailability
• EfficiencyEfficiency
• CompetencyCompetency
• ConvenienceConvenience
• AvailabilityAvailability
• EfficiencyEfficiency
• CompetencyCompetency
• ConvenienceConvenience
The Demands of Consumer Driven Medical Care in 2008
““Financial success without quality is Financial success without quality is irrelevant and quality success irrelevant and quality success
without financial is unsustainable. without financial is unsustainable. They are inextricably linked.”They are inextricably linked.”
-Mark Werner, M.D.-Mark Werner, M.D.
CMO, Carilion Health System 2005CMO, Carilion Health System 2005
““Financial success without quality is Financial success without quality is irrelevant and quality success irrelevant and quality success
without financial is unsustainable. without financial is unsustainable. They are inextricably linked.”They are inextricably linked.”
-Mark Werner, M.D.-Mark Werner, M.D.
CMO, Carilion Health System 2005CMO, Carilion Health System 2005
Where are the constraints in our current system?Where are the constraints in our current system?
• Can we use the Theory of Constraints to exploit those constraints?
• Can we use the Theory of Constraints to exploit those constraints?
Theory of ConstraintsTheory of Constraints
• A management philosophy developed by Dr. Eliyahu Goldratt
• Geared to help organizations continually achieve their goals through application of a set of basic principles, processes, and logic tools
• A management philosophy developed by Dr. Eliyahu Goldratt
• Geared to help organizations continually achieve their goals through application of a set of basic principles, processes, and logic tools
Theory of ConstraintsTheory of Constraints
• “The Goal” – 1984
• Five focusing steps–Manufacturing
–Project management
–Supply Chain / Distribution
• Thinking processes–Marketing / Sales
–Finance
• “The Goal” – 1984
• Five focusing steps–Manufacturing
–Project management
–Supply Chain / Distribution
• Thinking processes–Marketing / Sales
–Finance
Before the 5 focusing steps of TOC:Before the 5 focusing steps of TOC:
• What is the goal of the organization?• What is the goal of the organization?
What is the goal of a medical practice?What is the goal of a medical practice?• To make money• To deliver high quality
(“Financial success without quality is irrelevant and “Financial success without quality is irrelevant and quality success without financial is unsustainable.”)quality success without financial is unsustainable.”)
• To make money• To deliver high quality
(“Financial success without quality is irrelevant and “Financial success without quality is irrelevant and quality success without financial is unsustainable.”)quality success without financial is unsustainable.”)
$ = (# patients X efficiency X effectiveness) - overhead
Five Focusing Steps ofTheory of ConstraintsFive Focusing Steps ofTheory of Constraints
1. Identify the system constraint
2. Decide how to exploit the constraint
3. Subordinate everything to the constraint
4. Elevate the constraint
5. Return to step one, but beware of inertia
1. Identify the system constraint
2. Decide how to exploit the constraint
3. Subordinate everything to the constraint
4. Elevate the constraint
5. Return to step one, but beware of inertia
Identify the system constraintIdentify the system constraint
• Where is the constraint in your practice?
• Is it in the right place?
• Is the physician the constraint?
• Where is the constraint in your practice?
• Is it in the right place?
• Is the physician the constraint?
Example: Suppose the front office is the constraint…Example: Suppose the front office is the constraint…
1. The constraint has been identified, so
2. Decide how to exploit the constraint3. Subordinate everything to the
constraint4. Elevate the constraint5. Return to step one, but beware of
inertia
1. The constraint has been identified, so
2. Decide how to exploit the constraint3. Subordinate everything to the
constraint4. Elevate the constraint5. Return to step one, but beware of
inertia
Example: Office morale is the constraintExample: Office morale is the constraint
1. The constraint has been identified, so
2. Decide how to exploit the constraint3. Subordinate everything to the
constraint4. Elevate the constraint5. Return to step one, but beware of
inertia
1. The constraint has been identified, so
2. Decide how to exploit the constraint3. Subordinate everything to the
constraint4. Elevate the constraint5. Return to step one, but beware of
inertia
The physician is the constraint. Now what?The physician is the constraint. Now what?
• How do we exploit, subordinate everything to, and elevate the physician?
• By relieving him/her of all duties that someone else in the practice can perform.
• How do we exploit, subordinate everything to, and elevate the physician?
• By relieving him/her of all duties that someone else in the practice can perform.
Family Team Care: Application of TOC to Medical PracticeFamily Team Care: Application of TOC to Medical Practice
• Family Team Care works because it exploits, subordinates practice resources to, and elevates the performance of the physician.
• Family Team Care works because it exploits, subordinates practice resources to, and elevates the performance of the physician.
Family Team CareFamily Team Care
The core of this innovation is an The core of this innovation is an
assistant who is capable of taking and assistant who is capable of taking and
documenting a complete and documenting a complete and
competent patient history for the visit.competent patient history for the visit.
The core of this innovation is an The core of this innovation is an
assistant who is capable of taking and assistant who is capable of taking and
documenting a complete and documenting a complete and
competent patient history for the visit.competent patient history for the visit.
Family Team Care
• Remove the physician from the most Remove the physician from the most time consuming part of the visit.time consuming part of the visit.
• Allow the physician to focus on only Allow the physician to focus on only the aspects of the visit that require the aspects of the visit that require his/her expertise. his/her expertise.
• Therefore, hopefully, more patients Therefore, hopefully, more patients could be seen without sacrificing could be seen without sacrificing quality of care or patient satisfaction.quality of care or patient satisfaction.
• Remove the physician from the most Remove the physician from the most time consuming part of the visit.time consuming part of the visit.
• Allow the physician to focus on only Allow the physician to focus on only the aspects of the visit that require the aspects of the visit that require his/her expertise. his/her expertise.
• Therefore, hopefully, more patients Therefore, hopefully, more patients could be seen without sacrificing could be seen without sacrificing quality of care or patient satisfaction.quality of care or patient satisfaction.
This Change Would:
• RN, LPN, or MARN, LPN, or MA
• DependableDependable
• Trustworthy Trustworthy
• Skill CapabilitySkill Capability
• PersonablePersonable
• RN, LPN, or MARN, LPN, or MA
• DependableDependable
• Trustworthy Trustworthy
• Skill CapabilitySkill Capability
• PersonablePersonable
Who is the Assistant?
• Quality of care has dramatically Quality of care has dramatically improvedimproved
• Quality of care has dramatically Quality of care has dramatically improvedimproved
Results of Family Team CareResults of Family Team Care
• More time to ask questionsMore time to ask questions
• More time focused on medical issuesMore time focused on medical issues
• Improved accuracy of chartsImproved accuracy of charts
• Improved documentationImproved documentation
• Increased availability Increased availability
• More time to ask questionsMore time to ask questions
• More time focused on medical issuesMore time focused on medical issues
• Improved accuracy of chartsImproved accuracy of charts
• Improved documentationImproved documentation
• Increased availability Increased availability
Improved Quality of CareImproved Quality of Care
HSRP Performance
10
30
50
70
90
2002 2007Year
Per
cent (%
) _ BP Control
Lipid Measurement
LDL Control
Anti-platelet Med
Smoking Cessation
Anderson HSRP 2002-2007Anderson HSRP 2002-2007
• Quality of care has dramatically Quality of care has dramatically improvedimproved
• Patient Satisfaction has Patient Satisfaction has improvedimproved
• Quality of care has dramatically Quality of care has dramatically improvedimproved
• Patient Satisfaction has Patient Satisfaction has improvedimproved
Results of Family Team CareResults of Family Team Care
Satisfaction with Manner of Treatment by Physician Hilton Family Practice
94.5
91.491.2
87.7
91.6
93.193.5
80
84
88
92
96
100
Apr-07 May-07
J un-07
J ul-07 Aug-07
Sep-07 Oct-07 Nov-07
Dec-07
Goal: 95%
Liklihood of Returning to Hilton Family Practice
92.6
88.9
92.793.5 93.1 93.4
96
80
84
88
92
96
100
Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07
Goal: 95%
• Quality of care has dramatically Quality of care has dramatically improvedimproved
• Patient Satisfaction has improvedPatient Satisfaction has improved
• Financial Performance has Financial Performance has improvedimproved
• Quality of care has dramatically Quality of care has dramatically improvedimproved
• Patient Satisfaction has improvedPatient Satisfaction has improved
• Financial Performance has Financial Performance has improvedimproved
Results of Family Team CareResults of Family Team Care
Collections
200,000250,000300,000350,000400,000450,000500,000550,000600,000
2002 Traditional
Only
2003 Traditional and
1 Assistant
2004 1-2 Assistants
2005 2 Assistants
2006 2 Assistants
2007 2 Assistants
• Quality of care has dramatically Quality of care has dramatically improvedimproved
• Patient Satisfaction has improvedPatient Satisfaction has improved
• Financial Performance has improvedFinancial Performance has improved
• Staff Satisfaction has improvedStaff Satisfaction has improved
• Quality of care has dramatically Quality of care has dramatically improvedimproved
• Patient Satisfaction has improvedPatient Satisfaction has improved
• Financial Performance has improvedFinancial Performance has improved
• Staff Satisfaction has improvedStaff Satisfaction has improved
Results of Family Team CareResults of Family Team Care
Comparison of Employee Satisfaction BPA Scores Between Hilton Family Practice and Riverside Medical Group
77.86 76.43 77.1
85.42
64.22 65.28
70.02
77.22
50
60
70
80
90
100
2004 2005 2006 2007
Tota
l BPA
Sco
re
HiltonFamilyPractice
RMG
• Quality of care has dramatically Quality of care has dramatically improvedimproved
• Patient Satisfaction has improvedPatient Satisfaction has improved
• Financial Performance has improvedFinancial Performance has improved
• Staff Satisfaction has improvedStaff Satisfaction has improved
• Professional Satisfaction has Professional Satisfaction has returnedreturned
• Quality of care has dramatically Quality of care has dramatically improvedimproved
• Patient Satisfaction has improvedPatient Satisfaction has improved
• Financial Performance has improvedFinancial Performance has improved
• Staff Satisfaction has improvedStaff Satisfaction has improved
• Professional Satisfaction has Professional Satisfaction has returnedreturned
Results of Family Team CareResults of Family Team Care
TransitionTransitionTransitionTransition
From Traditional CareFrom Traditional Care To Family Team CareTo Family Team Care
• A decision to change A decision to change
• Communication to others of the need Communication to others of the need to changeto change
• Development of incremental, modest Development of incremental, modest changes that lead to the final goal changes that lead to the final goal
• A decision to change A decision to change
• Communication to others of the need Communication to others of the need to changeto change
• Development of incremental, modest Development of incremental, modest changes that lead to the final goal changes that lead to the final goal
Principles of ChangePrinciples of Change
• PART 1 - Data gathering and communication of PART 1 - Data gathering and communication of the data.the data.– physician or assistantphysician or assistant
• PART 2 - Analysis of data and pertinent physical PART 2 - Analysis of data and pertinent physical exam.exam.– physician onlyphysician only
• PART 3 - Decision-making and development of a PART 3 - Decision-making and development of a plan.plan.– physician onlyphysician only
• PART 4 - Implementation of the plan and patient PART 4 - Implementation of the plan and patient education.education.– physician or assistantphysician or assistant
• PART 1 - Data gathering and communication of PART 1 - Data gathering and communication of the data.the data.– physician or assistantphysician or assistant
• PART 2 - Analysis of data and pertinent physical PART 2 - Analysis of data and pertinent physical exam.exam.– physician onlyphysician only
• PART 3 - Decision-making and development of a PART 3 - Decision-making and development of a plan.plan.– physician onlyphysician only
• PART 4 - Implementation of the plan and patient PART 4 - Implementation of the plan and patient education.education.– physician or assistantphysician or assistant
The Patient Visit: 4 PartsThe Patient Visit: 4 Parts
Abdominal Pain ⁙Agitation ⁙ Alopecia ⁙ Amenorrhea ⁙ Ankle Pain ⁙ Anorexia ⁙ Anxiety ⁙ Aphasia (Dysphasia) ⁙
Apnea ⁙ Asthma (Follow-up) ⁙ Ataxia Back Pain ⁙ Breast Lump ⁙ Breast Pain ⁙ Chest Pain ⁙ Confusion (Dementia
and Delirium) ⁙ Congestive Heart Failure (Follow-up) ⁙ Constipation ⁙ COPD (Follow-up) ⁙ Coronary Artery Disease
(Follow-up) ⁙ Cough ⁙ Cyanosis ⁙ Depression (Follow-up) ⁙ Diabetes (Follow-up) ⁙ Diarrhea ⁙ Diplopia ⁙ Dizziness
⁙ Dysarthria ⁙ Dysmenorrhea ⁙ Dysphagia ⁙ Dyspnea ⁙ Dysuria ⁙ Earache ⁙ Edema ⁙ Encopresis ⁙ Enuresis ⁙
Epistaxis ⁙ Erectile Dysfunction ⁙ Failure to Thrive ⁙ Fatigue ⁙ Fever ⁙ Flank Pain ⁙ Gynecomastia ⁙ Hallucinations
⁙ Head Injury ⁙ Headache ⁙ Hearing Loss ⁙ Heartburn (GERD) ⁙ Heel Pain ⁙ Hematemesis ⁙ Hematochezia ⁙
Hematuria ⁙ Hemoptysis ⁙ Hip Pain ⁙ Hives ⁙ Hoarseness ⁙ Hypercholesterolemia (Follow-up) ⁙ Hypertension
(Follow-up) ⁙ Infertility ⁙ Insomnia ⁙ Irritability ⁙ Jaw Pain ⁙ Knee Pain ⁙ Leg Pain ⁙ Lightheadedness – dizziness
⁙ Lymphadenopathy ⁙ Melena ⁙ Menometrorrhagia ⁙ Menopause ⁙ Mouth Ulcers ⁙ Muscle Weakness ⁙ Nausea ⁙
Neck Pain ⁙ Nocturia ⁙ Numbness & Paresthesia ⁙ Nystagmus ⁙ Obesity ⁙ Oligomenorrhea ⁙ Osteoporosis ⁙ Pain ⁙
Palpitations ⁙ Pelvic Pain ⁙ Polydipsia ⁙ Postmenopausal Vaginal Bleeding ⁙ Pre-Menstrual Syndrome ⁙ Pruritus ⁙
Purpura (Bruises/Bleeding) ⁙ Rash ⁙ Rectal Pain ⁙ Red Eye ⁙ Scrotal Pain ⁙ Seizure ⁙ Short Stature of Teenager ⁙
Shoulder Pain ⁙ Sleep Apnea ⁙ Strabismus ⁙ Stridor ⁙ Stroke (CVA) ⁙ Syncope ⁙ Tinnitus ⁙ Tremors ⁙ Urethral
Discharge ⁙ URI ⁙ Urinary Incontinence ⁙ Vaginal Discharge ⁙ Vertigo ⁙ Vision Change ⁙ Vomiting ⁙ Weight Loss
⁙ Well Baby Checks ⁙ Well Child Checks ⁙ Wrist Pain
Common Symptoms & DiseasesCommon Symptoms & Diseases
• Read pages 2-15 in the manual, Read pages 2-15 in the manual,
“Liberating the Family Physician”“Liberating the Family Physician”
• Watch both DVD’s in their entirety Watch both DVD’s in their entirety
• Requires about 2 hours of timeRequires about 2 hours of time
• Read pages 2-15 in the manual, Read pages 2-15 in the manual,
“Liberating the Family Physician”“Liberating the Family Physician”
• Watch both DVD’s in their entirety Watch both DVD’s in their entirety
• Requires about 2 hours of timeRequires about 2 hours of time
Education of the PhysicianEducation of the Physician
Thank you for your interest in TOC Thank you for your interest in TOC and Family Team Careand Family Team CareThank you for your interest in TOC Thank you for your interest in TOC and Family Team Careand Family Team Care
• Peter B. Anderson, MDPeter B. Anderson, MD– Medical Director, Riverside Hilton Family PracticeMedical Director, Riverside Hilton Family Practice
– [email protected]@gmail.com
• Charles O. Frazier, MD, FAAFP, CPHIMSCharles O. Frazier, MD, FAAFP, CPHIMS– Vice President, Clinical Innovation, Riverside Health Vice President, Clinical Innovation, Riverside Health
SystemSystem
– [email protected]@rivhs.com
• Peter B. Anderson, MDPeter B. Anderson, MD– Medical Director, Riverside Hilton Family PracticeMedical Director, Riverside Hilton Family Practice
– [email protected]@gmail.com
• Charles O. Frazier, MD, FAAFP, CPHIMSCharles O. Frazier, MD, FAAFP, CPHIMS– Vice President, Clinical Innovation, Riverside Health Vice President, Clinical Innovation, Riverside Health
SystemSystem
– [email protected]@rivhs.com