“Business Improvement and Redesign in Healthcare using Lean Thinking”

Dr Chris Bollen,

MBBS DipPM MBA FRACGP FACHSM

Director, BMP Healthcare Consulting

The magic of management at work!

Overview• Why redesign Healthcare practices?

– It’s all about the waste!

• Case studies about improving value in healthcare practices➢Time

➢Money

➢Space

➢Goodwill

➢Use of workforce

➢Improved patient outcomes!

Why we need to be here ...

Improving safety and quality

• “Everyone in health care should have 2 jobs: to do the work and to improve how the work is done”

IHI CEO Maureen Bisognano 2012

Organisational readiness

What do you not like doing?

• Wasting time, spending money?

• But frequently practice owners are not spending time (on the business) and are wasting money!

Working smarter?

• The evidence is not that we need to work harder to do the right job, but we need to do things differently to get the right jobs done

• We need to change the way our practices are organised, staffed and deliver the care

• We need to change the way we think!

Why Business (Process) Redesign?

• Internal drivers– Staff turnover

– Burnout

– Sick leave

– Errors

– Complaints

– Workforce

– Space

– Finances

• External drivers- Customer satisfaction- Policy changes- Customer needs- Medicare changes- Funding models- Accreditation- Requirement for outcomes- Technology change

Lean thinking

• not a manufacturing tactic

• not a cost-reduction program,

• is a management strategy applicable to all organizations because it has to do with improving processes.

• Doing more with less

Business sustainability

• It’s not just about cost containment!

• Develop new revenue streams or die!

• A Healthcare Practice is no different………

• Moving towards value driven healthcare rather than purely volume

Customers vs patients?

• Customers ultimately define value and determine an organization's success.

• Without a customer focus, a Healthcare Practice risks missing what matters most in achieving it’s mission.

• the needs of the customer groups can be prioritized and matched with specific services

• Concept of “underserved market”.

Teams and Systems Thinking

SA Health

The key concept in lean thinking is ‘value’

• Value is defined: the capability to deliver exactly the service a customer wants, when they want it, at an appropriate price

• By defining ‘what customers want’, process-steps can be divided in value-adding and non-value adding.

The key concept in lean thinking is ‘value’

• Value adding activities contribute directly to creating a product or service a customer wants.

• Non-value adding activities do not = waste.

• Improvements achieved by reducing unwanted variation in processes.

Lean Principles

Flow impact

• An inefficient workflow is a problem in any business.

• In healthcare practices, workflow inefficiencies create:

– longer waits for patients,

– frustration for office staff

– burnout for health professionals

Patient Flow and Care Impact?

1. Minimize undue waiting,

2. + make destinations within the practice obvious,

3. + ensure timely transitions among staff patients feel well cared for + maximize daily patient load + increase clinician satisfaction

Flow 3 key points

1. Engagement across the practice

2. Chart your flow

– Map the flow

– Cycle time measurements

3. Address your bottlenecks

– Visit planning

– Office design

Toilet humour!

Improving Flow

Metrics that matter!

• Feeling frustrated with care you provide?

• Do you know what care you provide?

• How do your patients feel about you?

• How does your team feel?

• What do the funders think about the care?

Lean thinking

• Begins with driving out waste so that all work adds value and serves the customer’s needs.

• Identifying value-added and non-value-added steps in every process is the beginning of the journey toward lean operations.

• Lean means using less to do more.

Waste = Muda

• Anything that does not add value to the final product or service, in the eyes of the customer

• an activity the customer wouldn’t want to pay for if they knew it was happening.

• Measured in time, effort, money

– Example: waiting

Value stream

• The specific activities/processes required to provide a specific product or service in your practice

– “End to End” care

– “Patient journey”

Value stream mapping

• can reduce waste and improve patient plus staff satisfaction.

• Helps understand what really happens in your practice.

• Use the map to make improvements.

• Useful if you are willing to think differently + not happy with the status quo

Value Stream mapping

Identification of all the specific activities occurring along a value stream for a product or product

family (or service)

Process1 Process2 Process3

Product Family

• Understand all the work your health care practice does

• Describe it

• What is the same and what is different?

– Acute vs chronic consults

– Reactive vs proactive consults

– Forms vs diagnostics

– New vs review patients

– Consults vs treatment room

“5S” principles to reduce waste• Sort for necessity

• Simplify the workplace

• Shine for cleanliness

• Standardise processes

• Sustain standard processes

Muda

Going to the Gemba• Japanese term meaning "the real place.”

• gemba refers to the place where value is created;– in manufacturing the gemba is the factory floor.

– In healthcare, it is where the service provider interacts directly with the customer/patient

– “Moments of Truth”

• The problems are visible, and the best improvement ideas will come from going to the gemba

• The gemba walk, takes management to the front lines to look for waste and opportunities for improvement.

So what does that look like?

Template of the past!

Medicare Item Number Lotto–Patient Diagnosed with Diabetes

GPMP Item 721 Review every 3 months Item 732

TCA Item 723 Review every 3 months Item 732

PN/AHW Item 10997 (5 per annum)

Indigenous additional 10998 (5 per annum)

Diabetes Cycle of CareReview every 3 months Item 36 Item

2517/2521/2525 at completion of 12 months

MHTP Item 2700/2701/2715/2717

Review 1 – 2 times annually Item 2712

75+ Health Assessment Item 701/703/705/707 Repeat Annually

~ $862 annually

Pareto• Because most decisions are made under

uncertainty, the vital few must be identified if a program of improvement is to succeed.

• the importance of the vital few lies in the fact that nothing of significance can happen unless it happens to this (20%) segment.

• In 1937, Joseph Juran stated that this principle also applied to defects, concluding that 80% of the problems are caused by 20% of the defects—and he named this effect the Pareto principle

Case studies

1. Pathology downloads2. Waste and paper correspondence3. Lean xrays4. Muda and space5. High risk older people6. Patient Centred Gastroenterology Clinic7. Lean Diabetes Care8. Safe Care9. The New Patient

Case study 1: Less paper is value

Moving from paper to electronic downloads of pathology results-2001

Could not convince doctors it was the way forward until true inefficiency documented – “unlocked the value”

A. process mapping of what was currently happening

B. measured the time each step took for each person involved

C. quantified how many times the process occurred in the practice

D. quantified how much time and salary was being spent on the process

E. remapped the process with the technology change

F. quantified the up front costs required and the annual savings in time and salary for each person involved

Case 3: Improving staff and patient experience

Impact of team well being?

“How can we expect a patient to give today’s treatment experience a 5 /5 for satisfaction when the “Directors of First Impression”, doctors and nurses that cared for them would score their satisfaction with their work day and their organisation a 3/5 or worse?”

55

Not so lean x-rays1. GP orders X-rays when patient attends for a

consult2. Patient has X-ray3. Usually the X-ray packet is sent to GP practice

and has no report4. X-ray packet received by staff from courier (1-2

mins)5. Practice files X-ray awaiting next appt. (1-5 mins)

NB: Practice system needs to be orderly to find the X-ray. Storage required. – Steps taken to store/file the X-ray packet.

Xrays1. Patient makes appt via phone or on line but no mention

this is linked to an X-ray follow up

2. Comes to see GP , checks in with front desk. – May bring X-ray to appt…..– Smart practice's will annotate patient notes that X-ray has

been stored

3. This triggers staff to manually retrieve X-ray from storage– Steps to walk, time to find, steps back to give to person

who is waiting in the line. (1-5 mins)– Queue forms……– Experience level dropping for all concerned

4. Handover X-ray to patient (30secs)

Xrays

1. Patient sits with packet in waiting room

2. GP calls patient – opens packet In room (10 secs)

3. Looks at X-rays on wall viewer (1 min)

• If front desk unaware of X-ray, patient sits, waits, sees GP, GP requests X-ray from front desk, staff leave front desk to get X-ray and take to GP ( now GP and front desk patients all waiting---waste!!)(add 5 mins…..)

Xrays

1. Discusses report which may or may not be in packet

2. Puts X-rays in packet (10 secs)

– (Many patients and GPs report not even looking at X-rays and just review reports)

3. Gives X-ray pack to patient and finishes consult

4. Patient takes packet (some forget!!! require phone call to remind to pick up…)

Xrays

• 3 mins -12.5 mins in the steps taken which could be improved/removed

• practice staff time

Lean Xrays!

1. GP orders X-ray2. Patient has X-ray3. Patient makes appointment4. Attends practice , checks in and waits5. GP calls patient6. Consult-> opens image viewer (time the process)7. Finds patient (time the process)8. Views X-ray (1 min)9. Discusses report and findings10. Finishes consult/ closes intelliviewer (time the process)• 16 steps to 10

Impact on waste!

• On an average day:– How many patients with X-rays?

– Say 5 doctors working

– Each has one X-ray review per day

– 5 x 3-12.5mins

– Potentially 15-62.5 mins saved per day !!!!!

• More time spent on other activities with greater purpose

From Triple to Quadruple Aim

• “Our ability to achieve the triple aim is jeopardized by the burnout of physicians and other health care providers.”

• New goal: “Improving the work life of health care providers, including clinicians and staff.”

# Bodenheimer, T., Sinsky, C. From the Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider.

Annals of Family Medicine, Inc.,: 2015.

Case study 4: Muda and space

• A practice with limited space and increased ageing population

• Needed more GPs to handle patient demand

• GPs struggling to get to nursing homes at lunch time/before work/after work

• Home visits not getting done + more locums being used after hours

• Stressed GPs

• Quality of patient care concerns

• GPs sitting in consulting room alone doing paperwork

“Management’s overall aim should be to create a system in

which everybody may take joy in his/her work.”

Dr. W. Edwards Deming

Waste 3Ms• Muda: some of the 8 wastes illustrated

o Defects

o Waiting

o Non utilised people

o Transportation

oMotion

• Muri: overburdened GPs trying to do too much across the day

• Mura: GPs being called to RACFs episodically is uneven workflow

“Push system”

Episodic GP visits to RACFs impact:

o GP less able to visit when resident unwell

o Locum service called after 1800

o Quick assessment/too complex for doctor without required skillset (but is paid the most so the wrong outcome has been rewarded!)

o Resident sent to Emergency Department

“Pull system”

• Providing the care when patients want it

– having a spare doctor available in the treatment room allowed acutely unwell people to be seen by duty doctor

• GPs visiting RACFs at regular times for “sessions” allow staff to discuss all residents, and early interventions result

• Greater efficiency

• More planning and use of other item numbers

Product families

• Residential Aged Care Facility visits

• Home visits

• Acute care

• Regular consultations

Value streams developed

• Older people

• Acute care

• Helped understand:

– Workforce utilisation

– Room utilisation

New model• Practice moved from 5 to 8 GPs• Every GP works 1/2 day in the practice and 1/2 day

outside • Better planned care of older people (RACFs and home

visits) • Reduced number of older people attending EDs• Less locum services used after hours• Increased income stream with no change to cost base• Shared hub for paperwork • Up skilling encouraged• Happier GPs + Better Care + Better Access

Case study 6 : Patient Centred Gastroenterology Clinic

• Issue: Aim to improve care of people with inflammatory bowel disease

• Wastes identified:– Patient time (waiting, time being unwell, going to EDs)

– Unnecessary anxiety-> QOL impact

– Doctor time + “reduced joy”

– Use of hospitals

– Use of narcotics

– Use of radiology

Current process:

1. Patient books for clinic

2. Waits in WR……….

3. Sees doctor/nurse Standard questions by doctor: time ticks by responding to questions about bowel movements, blood in their stools, and other indicators of disease activity

– Time spent on “what matters to the doctor”, often not increasing education/knowledge or proactive care for patient

Outcomes

1. Waiting time an issue

2. Engagement and Satisfaction levels low (patient and doctor)

3. Flare ups occur patient attends EDs = unnecessary or harmful care — including steroids, narcotics, and CT scans —due to an lack of disease knowledge in the ED.

4. Waste of time, money, resources!!

New process:1. Patient books for clinic

2. Waits in WR + WR questionnaire asks, “What matters to you most today” - #1 concern about Inflammatory bowel disease + usual doctor questions re: bowel movements, blood in their stools, and other indicators of disease activity

– Time spent with doctor on “what matters to the patient”, increased engagement as patient’s issues addressed

Impact?

1. Waiting times reduced

2. Satisfaction levels for doctor and patient increased

3. Education regarding proactive care increased

4. Flare ups decreased Reduced use of EDs and narcotics = safer and more effective care

– > And reduced cost of care

– > Quadruple aim achieved!

Case study 8: The new patient

• New General Practice set up in country town

• Low socioeconomic region

• Bulk billing not attractive to new doctors but attractive to patients

• How to deliver effective care at lower cost?

• How to increase patient satisfaction? (and loyalty)

• How to create new revenue streams early?

Understanding the value stream

• MBS item numbers

• Practice incentive payments

• Practice population demographics

• Shifting trends

• Acute episodic care vs Chronic disease care

• Doctor vs nurse utilisation

Workforce

• Who is best placed to do the role?

• Identify all parts of the role

• Training for the role

• Satisfaction with the role patient + health professional!

New model• Every new patient booked has 30 minutes

with the nurse

• Allowed time to explore background of the person

• The nurse was trained in whole person care, prevention and early intervention

New model

• Nurses understand the value stream of prevention and book people early for:

– the 45-49 health assessments,

– diabetes screening,

– Chronic disease care planning

– Accessing services via Team care

• while the GPs do what they like doing-working with acutely unwell patients, diagnosing and prescribing.

New model

Great example of:• End to end care

• Pull systems

• Reducing waste

• Increasing value

• Measuring and reviewing data

• Patient centred approach

• BUT some doctors still need convincing!

• Patients very happy- needs being met

Seeking perfection

• In healthcare we often continue to work, thinking the more we do, it will get better but this is analogous to:

– “we can’t stop chopping wood to sharpen the axe, and so we just continue using a blunt axe!”

• The importance of continuous quality improvement or kaizen

12 minute interview

• 1-2-1 time becomes part of practice culture

• Helps avoid losing touch when you’re busy

• Requires planning and a rotating schedule

• Commitment by the leader

• What is important will come up

• An investment of your time in your people

• Finds the “pebbles in the shoes”

12 minute interview

Questions/Feedback?

Dr Chris Bollen

Contact details:

0412952043

chris.bollen@bmpconsulting.com

LinkedIn

Twitter @BMPConsulting

Who is BMP Healthcare Consulting?

Jane Bollen

Registered Nurse background• Certificate Critical Care (RAH)• Diploma accounting• GP Plus Practice Nurses training• Worked in multiple General

Practices• APCC Quality Improvement

Advisors Committee• AGPAL Surveyor• Board member APNA

Who is BMP Healthcare Consulting?

Chris Bollen

GP background• FRACGP• Diploma practice Management

(UNE)• Director GP Training TQEH• MBA (University of Adelaide)• CEO, Chairperson and Treasurer of

various dynamic healthcare organisations during career

• Lean Thinking in Healthcare (Flinders University)

• FACHSM

Lean Principles

Innovation and strategy

• Do we want to do a better job or do we want to do better things?

• When time is a scarce resource, need to learn to let go of some tasks, or reduce the steps

• Do we want medical practices with impressive levels of quality and reliability?

• Roles of technology

Common principles

• Customer must be central to everything

• Work processes should be categorised, redesigned if necessary, and understood as components of a wider system

• Measuring components of the process and understanding the importance of variation in these measures is fundamental

• The expertise of people who work on the frontline should be recognised and valued

Case study 2: Waste and Communication

• Recognise and Identify the problem

• Map the process

• Understand the value

• Identify the waste along the way

The Problem

• General Practice is inundated with paper letters being sent by other health care providers

• BEACH data-> what has changed?

• Information is being handled many times by multiple people in a practice

• Highly computerised profession

• Large amount of waste

Identify The Waste

• Staff time

• Scanning documents and memory

• GP time▪ Handling paper

▪ Finding the scanned document

▪ Reading a scanned document

▪ Information not in a useable format

• Poor transfer of information downstream has safety and quality impact for patient

Quantify The Waste• Staff time Money and efficiency • Scanning documents and memory Server size

costs more + slows computers• GP time

▪ Handling paper unpaid time▪ Finding the scanned document consult time▪ Reading a scanned document consult time▪ Information not in a useable format consult plus unpaid

time

▪ Poor transfer of information downstream has safety and quality impact for patient System waste

Why would a health professional practice not want to use secure messaging ?

Health professionals and IT

• " the aim of health informatics is to lead to improved healthcare delivery, improved services. It's about efficiency, working smarter, not harder.”

• Health informatics is about using information to improve healthcare outcomes.

• Secure messaging can enhance health informatics.

Current 12 steps in receiving patient clinical information

• receive paper letter in mail• letter opened by admin team member• letter placed in GP in-tray, (or some practices scan

the letter and have a holding file for GPs to review)

• GP eventually takes letter out of in-tray• GP reads and signs letter and actions any issues

(or reads scanned document and annotates what is required using radio buttons)

• any new medical history is added to file (all information is typed in) either at this point or is added at next consult

Current 12 steps in receiving patient clinical information

• letter is put in out-tray by GP

• admin staff remove letter from out-tray and take letter to scanning pile

• admin staff scan letter,

• admin staff upload letter to appropriate patient file,

• admin staff add an appropriate file name(!)

• paper letter is either filed for period of time or is shredded

Using secure messaging the number of steps is reduced to 3:

• secure message downloaded as per pathology/radiology into GP holding file automatically

• GP checks results which include the letters and annotates what is required using radio buttons (letter automatically uploaded to patient file as per radiology/pathology)

• any new medical history is added to file (all information is typed in) either at this point or is added at next consult

Challenges!• No directory of health care providers with

SEM

• 4 major vendors of SEM but not interoperable

• GP software vendors have not made “the right thing easy to do” in order to send information via SEM

• Other healthcare providers think usual email is OK for patient information

Business benefits

• Save time by not trying to decipher the hand-written information. (safety!)

• Reduce scanning and faxing.

• Save time by not having to call other practices looking for ‘lost’ referrals.

• Reduce the number of queries between referrer and referee.

• Improve process of referral transfer to ensure that the right consumer information is held in the right place.

• Improve communication between specialists and general practitioners due to the timely availability of information, eventually leading to improvements in quality and safety of patient care.

Business benefits

• Save time by not having to spend hours printing, folding and putting referrals in envelopes.

• Reduce the number of letters sent and received and eliminate the need to fax referrals.

• Reduce postage and stationery costs.

• Reduce the size of your database as you will not need to scan letters into the system.

Lean principles

• Improved flow due to less interruptions searching for information and less delays in care during the consultation

• Reduces waste in the system across a busy practice

Case study 7: Diabetes care

• Problem: 800 patients with diabetes

• Low number of patients receiving “cycle of care”

• Wastes:

– People not receiving “expected care”

– Variation in care

– Practice missing out on significant funding

– Access to practice poor as focus on non-planned care

Existing system

• Episodic encounters

• 800 patients may or may not present to the practice at least twice each year

• $68,800 minimum potential revenue annually

• GP time 400 hours/annually minimum

Steps to Lean Diabetes Care

• Present the current outcomes (data from PENCAT and practice billing software)

• Establish dissatisfaction with current outcomes is shared across the group

• Map the current “process of care”

• Review the map with group to establish where there is “loss of value” and “waste” occurring

• Map new process + delegate people

Steps to improve

• Data shared across practice

• 3 monthly practice meetings on topic

• Reflections on current process (“the system”)

• Shared approach to changes in process

• Agreement document

• Recruitment of new nurses

• Review of data

Keep people informed

Value streams

• Remember the “End to End Patient Journey”

• MBS item numbers

– 721/723/732 (care plan/team care/reviews)

– 10997 (practice nurse)

• Practice Incentive payments (PIP)

• Patient outcome data (PENCAT)

• Patient feedback

ANNUAL CYCLE OF CARE (CoC)

• Assess Control by measuring HbA1c Yearly

• Ensure comprehensive eye examination Biannually

• Height / Weight calculate BMI 6 monthly

• Measure BP 6 monthly

• Examine Feet 6 monthly

• Lipid Levels Yearly

• Test for Micro-albuminuria Yearly

• Provide self care education Yearly

• Review Diet / Physical activity Yearly

• Review Medication Yearly

• Check smoking status / Immunisation Yearly

Value for the diabetes “product family”

• Each patient with diabetes

• Over a 2 year cycle

• Requires defined baseline care

• And the value created is…….

Value for the diabetes “product family”

• Each patient with diabetes 800

• Over a 2 year cycle will have a minimum of 4 planned appointments with nurse and GP (210 mins nurse + 60 minsGP)[2800 nurse hours +800 GP hours]

• Requires defined baseline care (annual CoC achieves incentive payment $40 per patient)

• And the value created is……. $372,000 for the practice, and better health for the patients?

“Pull system”The receiving group go “looking for the next patient”

o Recall systems for health checks

o Chronic disease registers used to view who is not getting appropriate care

o Identifying “high risk” people

▪ Clearly understood responsibility and accountability with people at each step (patient receives recall letter, rings practice receptionist, booking made for nurse followed by GP)

“Pull system”▪ Agreement about what is required:

▪ Nurse responsibility for the diabetes register▪ Handover between Nurse/GP/Patient for care plan

▪ Standard template of care plan used▪ Send recall letter explaining “value of the visit”▪ Focus on patient goals (value) ▪ Structures to support engagement:

▪ Regular team meetings▪ Education for receptionists▪ Access to training for nurses (motivational

interviewing, local resource options, roles of exercise physiologist, dietitian, DNE)

Outcomes

• More nurses recruited for Chronic Disease clinics (14 hours increased to 35 hours/week)

• System changes

• Patient care changed – Focused on Patient Goal vs medical goals

– Increase in standards of care

– Access to more services

• Increased GP/practice revenue

• Staff satisfaction

Other potential improvements

• ECG every 1-2 years (11700 $31)

• Doppler arterial pressures every 1-2 years (11610 $64)

• Home Medication Reviews (900 $152)

• Increased PIP payments

• Data manager role

• Understanding of the value of a system for managing Chronic Disease in a practice

Impact on waste

• Use of GP time

• Use of nurse time

• Use of patient time

• Use of admin staff time

• Aim to reduce diabetes complications by early interventions

• Benefits of care in the “end to end process”

Case study 5

How do you feel…….?

Do you know your population?

• How many people aged 75+ living in the community?

• Health assessments-surgery or in the home

• + how many care plans and care plan reviews are occurring for this complex group?

Why do Health Assessments?

• “The main purpose of health screening in vulnerable groups is to facilitate timely and appropriate interventions to prevent further decline in function or complications associated with chronic conditions” (Gray and Newbury 2004)

• Low take up (<20% of older people)

• Evidence for impact and value?

• Are the templates fit for purpose?

• Barriers for older people?

Batching

• Make the complex simpler by:

– Reducing steps and duplication

– Improving information transfer

– Make the customer experience better

– Breaking down siloes

– Maximising value for end to end care

Health assessment and Care Plan/TCA (Review)

• Less visits

• Better use of time

• Better use of team - one person not 2

• Increased billing for time spent

• Continuity of information and planning

• Increased value for all