Re-Engineering Lean Care
Management and Automation in
a Value-Based World
Jerry Green Kristy Sanders
March 30, 2016
Housekeeping
1. Using the control panel ‐Use the control panel on the right side of your screen to minimize and expand this panel by clicking on the arrow in the upper right corner. 2. Ask Questions ‐You can submit questions using the Question section located near the bottom of the control panel. We will take time to answer as many questions as we can during Q&A at the end of the presentation. If your question was not answered, we will respond to you individually after the event. 3. After the webinar ‐ We want your feedback! Please take the short survey at the completion of the webinar. Also, all registrants will receive a copy of the presentation, and the recording for on‐demand replay.Agenda
• Why LEAN and Automation?
• The five LEAN Steps & Strategies
1. Value
2. Map
3. Waste-flow
4. Implement-Pull
5. Maintain-Perfection
• In Conclusion
• Q&A
WHY LEAN AND AUTOMATION?
Technology
IBM WH EMR MIDAS Etc…People
Knowledge,
Skills,
Abilities
Process
Ways of
Working
Why LEAN? To Optimize all three bubbles
Training & Experience
Training & Experience
Processes
Processes
Automation
Solutions
Tools
Automation
Solutions
Tools
KNew technologies change the way people work
Process flow optimized and aligned
to the
technology Upfront pre-visit planning eliminates downstream rework cycles Team members collaborate in huddles to prepare for patient arrivals Downstream wait time is eliminated as workers and supplies are ready when the
patient arrives Patient is
ready with Labs, Med
list, etc All team members
ebb and flow to keep patient moving through the work flow
without waiting or interruption
Patient is at the top of the
clinical universe
Upfront pre-visit planning is most efficient at
reducing care gaps. All other methods require
getting the patient back in the office.
They’re already here!
All team members work at the top of license (what is legally allowed] Percentage of “No Shows” reduced with remind
An uninterrupted flow for the patient is the end goal
Chart not meant to be read
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DEFINE
VALUE
FROM THE
PATIENT’S PERSPECTIVE
Satisfaction
Dissatisfaction
Functional Dysfunctional
Kano Model
Brainstorming using the KANO Model can help identify
patient satisfiers and dissatisfiers
Expected: Patients clearly ask for this
Basic Needs: (Must Haves) Patients expect this without having to ask for it
Items move down over Time
If included, patients/customers will be satisfied
If omitted, patients/customers will not be dissatisfied
If included, patients/customers will NOT be satisfied If omitted, patients/customers will be dissatisfied
Wow: Delighters Patients don’t know it
exists.
KANO
• What’s important:
– To not forget Basic Needs – To reaffirm what the
customer’s are asking for, the Expected Needs
– Not trading Basic Needs for Wow’s
– To ensure that all
stakeholder needs are
cared for in the new design
No Charter No Project
• Problem:
– Lower HbA1c for diabetic patients with scores >=9 • Entity: Patient
• Goals: Improve HbA1c testing rate by 5% by end of Q?
Less than 15% >9 by Q? • Champion: CMO
• Project Leader: Quality Manager • Project Team: SME’s
• Due Date: dd/mm/yyyy
© 2015 International Business Machines Corporation
MAP
THE VALUE STREAM AND
IDENTIFY ISSUES
To identify all inputs for a process use the 5M & P Method
People Method Machine Material Measurement Mother Nature Physicians Nurses Analysts Patients Programmers Etc… Processes Methods Check Lists Approaches Workflows Etc... Laptops Medical Eqp. SW Programs Vehicles Routers Etc… Sponges Paper Glue Tile Desks Etc… Thermometer Story Points Blood Pressure Lab Scores Coordinate Etc… Temperature Rain/Wind Policies HIPAA NCQA ISO Etc…
Using the 5M’s & P method can help identify what goes
into the map
• Brainstorm for each item and place on a sticky note next to the appropriate 5M & P heading
Methods Processes Materials Supplies Mother Nature Policies, Weather Measurement System
How things are measured
Machines
Equipment, HW & SW
People
Any person
Always map the current state in detail
• Effective change agent
– Evokes an emotional response • Becomes a common language
• Identifies sources of waste (NVA)
• Identifies the potential inputs, actions and decision points that may impact a
process and its outputs
• Serves as the foundation for process improvement activities
“…and then it ends here” Start here
Visual and
engaging! Easy to do!
Use the LEAN criteria to identify non-value add
activities (NVA) in the map
The LEAN criteria
1. The patient must care about it
AND
2. The activity must change the patient or knowledge about the patient
AND
To identify non-value added activities, it helps to think
about the 8 LEAN Wastes in the Muda Wheel
Defects - incorrect data entry, incomplete information, mistakes
Overproduction- Preparing extra reports, making too much
Waiting– Batching work, downstream step is not ready uNused Creativity - Not working at the Top of a License
Transportation- Travel to/from facilities, walking to copy machine
Inventory - Purchasing supplies in bulk and storing in cabinet
Motion - Extra steps and movement during an exam
Excess Processing - multiple sign-offs, most meetings, downstream inspections, rework, approvals
Defects Transporta-tion Over -Production Waiting Motion Unused Employee Talent Inventory Non Value Added Processing Waste “muda”
Using a Fishbone (Ishikawa Diagram) with the 5M’s and
P and the 5 Why can help identify root causes
K
1. The Problem statement is the Fish head 2. Use the 5Ms and P as the major bones
3. Use the 5 why process with each failure mode to move from symptoms and get to the root causes for each bone
ELIMINATE WASTE
AND
ALLOW THE PATIENT TO
FLOW
THROUGH THE VALUE
STREAM WITHOUT
INTERRUPTION.
Ensure continuous flow in your design so the entity
(patient) never waits
IDLE WORKERS
VS
Waste elimination Strategies at a 50k foot level
Once Waste is identified:
1.First Priority: Eliminate (do not improve an activity that should be eliminated)
2.Second Priority: Automate • Poka Yoke
• Auto populate 3.Third Priority: Simplify
• Reduce handoffs
• Eliminate redundancy
• Co-locate and sequence tasks • Reduce approvals
• Standardize
• Reduce motion • Prioritize efforts
• Balance resources • One piece flow
• 5S
One way to ensure defects are eliminated is through
Poka Yoke and Automation
• Definition of “Poka-Yoke”:
– Japanese for “Mistake-Proof” • Two Types
– Detection – detects defects which have already occurred
– Prevention – predicts and/or prevents defects from occurring
Error Proofing Spectrum
Most processes
Awareness Detection
None Instruction Training/ Visual Aids Visual Guidelines Containment 100% Inspect Defect Detection •Warning •Shutdown Defect Prevention •Control Prevention Reactive Proactive Passive
Poka Yoke Ideas
• Reduce NVA by eliminating rework loops, auto populating data entry – Drop down menus for data entry
– Color coding items that go together
– Manual processes automated (not manumated) – Electronic sensors for danger areas
– Bar coding
– Collision detection systems
– Correct position setting tape so item is always placed in the correct location
– Barriers to electronic files
– Computerized Physician Ordering Systems – Plug protections for children
http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/mistakeproof/mistake8.html
K
Ideas for Leaning out the 8 Types of Waste
Type of Waste Definition Example Solution
Defects Errors resulting from omissions, inaccurate information, or mistakes. Often results in lost capacity from rework and can cause harm.
Use algorithms to evaluate patient “care gaps” against evidence-based guidelines and take action to close them with automated patient
communications & provider alerts. Over Production Providing more services that
needed, including redundant services.
Query integrated patient registry before ordering tests and services for patients.
Waiting Idle time for the patient usually due to waiting for needed information, action, or resource.
Build in “same day” appointment slots to improve access; redesign visit preparation process with daily huddles and new roles for care team members while rooming patients. uNused Creativity Unused talent an skills. Not working
at top of license and legal allow ability.
Train medical assistants to do health coaching; delegate or automate nonclinical tasks to maximize use of clinical team members’ specialized skills.
Source: Handmaker, K., Green, J. (2014). Lean Care Management
and Automation. Retrieved from http://resources.phytel.com, April 15, 2015.
Ideas for Leaning out the 8 Types of Waste
Type of Waste Definition Example Solution
Transportation Moving people, equipment and supplies. Walking or driving to and from. Represented by the lines in a value stream map.
Do lab testing in the office instead of sending patients to another location. Inventory A supply of resources stored while
waiting to be consumed by patient demand.
Survey patients to determine best days, times, and locations to hold group education sessions so “supply” matches demand.
Motion Movement when in a stationary area while performing tasks.
Co-locate physicians and medical assistants in “pods” to eliminate extra steps to communicate (messaging, walking); utilize automated reporting and alerts to minimize “clicks” and research time.
Excess Processing More work being done than what is required by the patient. Includes doing more that than absolutely necessary.
Ask patients to only update new information instead of completing the same profiles at every visit.
Source: Handmaker, K., Green, J. (2014). Lean Care Management
and Automation. Retrieved from http://resources.phytel.com, April 15, 2015.
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IMPLEMENT
THE IMPROVED
PROCESS AND LET THE
PATIENT
PULL
THE VALUE
Kotter’s 8-Steps for Managing Change 1.
Create a sense of urgency
2. Form a guiding coalition
– Those who can help move the project forward – Up and down the organizational hierarchy
3. Create a vision of the future
4. Communicate the vision
5. Empower action
6. Create short term wins
7. Don’t let up
8. Make change stick
Kotter’s 8-Steps can help with change management
• No one from an upstream process, step or activity produces or moves the entity until the next downstream process, step or activity is ready for it
• Using a pull system makes delays and waiting transparent, pushing tends to hide the amount of time a patient waited in the system
– Transparency helps with optimizing scheduling – Less wait = higher patient satisfaction
– Less wait = increased velocity through the system
What is Pull?
28
Pull
Step 1 Step 2 Step 3 Step 4 Step 5
“I’m ready!”
MAINTAIN
THE GAIN AND
PURSUE
PERFECTION
Tweak to perfection using 5S
1. Sort: Keep only what is needed, discard everything else. Sort remaining into
categories
2. Store: A place for everything and
everything in its place. Store and label all items in an area that is easily visible and accessible to the group.
3. Shine: Keep the workplace tidy and
organized and labels obvious. Clean and tidy up regularly.
4. Standardize: All areas must be set up exactly the same way. Makes standards obvious and enforce them.
5. Sustain: Maintain, plan, schedule, train, track and audit all areas periodically.
Compare before and after measures
• Measure Before VS After and report on improvement
Before
After
Monitor and Close: Pursue Perfection
• Go back and review the Charter and patient values from the KANO • Redefine new and tougher targets
• Find additional waste to remove using the LEAN Criteria • It takes about 90 days for a change to stick
• Only the Champion can close the project
• Must insist on evidence that the project was successful and when doing more is not worth the cost to continue
• Monitoring and measuring the key measures must continue…FOREVER
IN CONCLUSION
End to end
Processing Approvals Rework
Technology
IBM WH EMR PeopleSoft Etc…People
Knowledge,
Skills,
Abilities
Process
Ways of
Working
Why LEAN? To Optimize all three bubbles
Training & Experience
Training & Experience
Processes
Processes
Automation
Solutions
Tools
Automation
Solutions
Tools
KA Guide to Lean Healthcare Workflows
This free guide delves into the five steps of LEAN as a detailed walkthrough:
1.Define value from the patient's perspective 2.Map the value stream, and identify issues and constraints
3.Remove waste, and make the value flow without interruption
4.Implement the solution, and allow patients to pull value
THANK YOU!
The recording and handouts will be sent to you via email within 2 business days
