Xtreme Makeover PCMH edition. The Miramont Story Presented by John L Bender, M.D., FAAFP May 4 th, 2013 Sonnenalp, CMS 2013 Spring Conference

Transcription

1 Xtreme Makeover PCMH edition The Miramont Story Presented by John L Bender, M.D., FAAFP May 4 th, 2013 Sonnenalp, CMS 2013 Spring Conference

2 Conflict of Interest Disclosure John L. Bender, M.D. Has no real or apparent conflicts of interest to report.

3 Learning Objectives John L. Bender, M.D. Recognize how NCQA recognition makes it possible to improve safety, efficiency, patient outcomes and profitability in the ambulatory care environment Illustrate the link between NCQA recognition and a successful Meaningful Use implementation strategy Summarize the business case for improved workflows, clinical quality and metrics (aka Registry Reporting)

4 Our story begins in Fort Collins Colorado H.G. Carlson, M.D. One of the oldest practices in Fort Collins Open 8-5 most days Paper Charts One Employee One Computer (386) 1000 patients

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6 In a basement, paneling on the walls

7 Walls of Paper Charts

8 Move that Bus!!!

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10 Our story today 2013 in Larimer County Colorado. 4 locations in 3 separate communities Open M-F 8-8, Saturdays providers 58 employees Electronic Charts, Patient Portal, NCQA III PCMH recognition Over 100 company computers operating in a terminal service environment and a centralized data center 30,000 patients Davies Ambulatory Award recognition from HiMSS in 2010

11 4 th fastest growing company in Northern Colorado

12 Miramont s Growth Curve year receipts volume 2001 $169, , , , , , ,449, ,940, ,616, ,505, ,356, ,804, ,000,000 4,500,000 4,000,000 year 3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000, ,000 0 receipts volume 2001 $169, , , , , , ,449, ,940, ,616, ,505, ,356, ,804, Miramont's Growth as measured by receipts

13 2010 HIMSS Ambulatory Award

14 2011 Colorado PCMH of the Year

15 34 primary care physicians leave practice during the same time specialty gender year of transition practice zip code event Family Medicine female closed/unable to service debt Family Medicine male Family Medicine male moved to work for Orthopedists Family Medicine male closed/unable to service debt Family Medicine male sudden death, age 52 Internal Medicine male sold/less profitable Internal Medicine male sold/less profitable Family Medicine male sold/less profitable Internal Medicine male sold/less profitable Family Medicine female closed/unable to service debt Family Medicine female closed/unable to service debt Family Medicine male closed/unable to service debt Family Medicine female closed/unable to service debt Internal Medicine male sold/less profitable Family Medicine female closed/unable to service debt Family Medicine male closed/? Internal Medicine male closed/moved to BTMG Family Medicine female I can not disclose under contract Gynecology male closed/divorce? OB/Gyn female ? OB/Gyn female ? Family Medicine female ? OB/Gyn female ? Family Medicine male unable to service debt Family Medicine male uncertain Family Medicine male offered job in Sports Medicine Family Medicine male sold/less profitable Internal Medicine female Internal Medicine male sold/less profitable Family Medicine male closed by CRMC, non profitable

16 8 are bankruptcies specialty gender year of transition practice zip code event Family Medicine female closed/unable to service debt Family Medicine male Family Medicine male moved to work for Orthopedists Family Medicine male closed/unable to service debt Family Medicine male sudden death, age 52 Internal Medicine male sold/less profitable Internal Medicine male sold/less profitable Family Medicine male sold/less profitable Internal Medicine male sold/less profitable Family Medicine female closed/unable to service debt Family Medicine female closed/unable to service debt Family Medicine male closed/unable to service debt Family Medicine female closed/unable to service debt Internal Medicine male sold/less profitable Family Medicine female closed/unable to service debt Family Medicine male closed/? Internal Medicine male closed/moved to BTMG Family Medicine female I can not disclose under contract Gynecology male closed/divorce? OB/Gyn female ? OB/Gyn female ? Family Medicine female ? OB/Gyn female ? Family Medicine male unable to service debt Family Medicine male uncertain Family Medicine male offered job in Sports Medicine Family Medicine male sold/less profitable Internal Medicine female Internal Medicine male sold/less profitable Family Medicine male closed by CRMC, non profitable

17 Hospital Movement IN the past 4 years: The number of EM physicians double, and ED utilization increases by 50%. IN the past 2 years: 250 physicians become employees of the local hospital owned medical group (600 total physicians in the county)

18 Our Product in 2002 Test results are slow Labor costs high with much non-revenue generating activity / waste No open appointments No clinical data management Barely any financial data management High variability in patient experiences from day to day Documentation illegible Unable to compete with retail clinics, urgent care, emergency departments, etc.

19 Wanting to get out of last century

20 Company Retreat August 2007

21 Ambulatory Medicine Needs to Have a Vision Where there is no vision, the people perish Proverbs 29:18

22 Positioning Statement: For local families desiring healthcare, Miramont Family Medicine is the choice that offers the most convenience and the highest value

23 Miramont Mission Statement to deliver compassionate, modern, timely healthcare in a clean, professional environment that promotes patient and staff growth, health, and happiness

24 The Restaurant with Bad Food

25 Made friends with the banker, accountant, attorney and local business leaders We decided it would take money to make money and the process starts with investing We pledged that we would make Miramont safer, more efficient, and up to date Ensure our own profitability at all times in order that we could be there for our patients for many years to come Eliminate as much as possible non-revenue generating activity Find ways to provide needed services in our house, in the free market health care system that we are given Find a better EHR (transition out of a free product we acquired in 2005) Attain NCQA recognition for a Patient Centered Medical Home

26 $1.4 million in new building in 2005

27 Every Year We Bring New Products and Services 2002 Female Provider, DEXA scanner 2003 Level 2 Laboratory, IV therapy 2004 Visiting Surgeon, 8-5 hours M-F 2005 New Building, X-ray, bilingual services 2006 Physical Therapy, Psychotherapy, After Hours 2007 INS, Coumadin clinic, Nerve Conduction studies, Saturday hours, Nurse Educator 2008 Female Physician, Colposcopy, Pain Management Specialist, Group visits, The Dispensary, Psychologist

28 Every Year We Bring New Products and Services 2009 Patient Centered Medical Home, New Website, patient portal, online registration, online scheduling requests, online bill payment, Miramont Value Plan (MVP), Allergy Testing and AIT, Second location and Third Locations, Laser Aesthetic Medicine 2010 Botox, digital Mammography, Audiology, Pediatrician, CEO level administrator, blast marketing to patient base, automated collections calls 2011DME sales, drive through pharmacy, fluoride dental treatments for children th location in Parker Colorado, self check in kiosks, Phreesia tablets, Medtronics Insulin pumps, ipro

29 THE PROCESS OF GAINING NCQA RECOGNITION or ACHIEVING MEANINGFUL USE IS A WORKFLOW REDESIGN PROCESS IN ITSELF

30 Quality Meaningful Use Basic Tenants in the PCMH/Specialist Practice Transformation: Physician Leaders who are willing to lead a team. Every person on the team must be empowered to contribute to process improvement and workflow redesign

31 Toyota Production Model The Toyota Production Model: The Toyota Way is built on two pillars, continuous improvement (kaizen), and respect for all people PDSA cycle Plan, Do, Study, Act

32 PDSA: Action Plan State the problem being addresses State the purpose of the proposed change State the specific AIM and associated measure State the action-oriented objectives What will be done!!

33 PDSA: Do State specific tasks to achieve each objective State who will do these tasks State timelines for completing tasks Who is accountable for getting things done!!

34 PDSA: Study Select qualitative and quantitative measures Complete analysis of measures Compare results with baseline values Summarize and reflect on what was learned from the data

35 PDSA: Study PDSA: Study Performance Measures Linked to Project Aims Types of Measures: How Well (efficiency) Impact (outcome) If you do not measure, you will not sustain redesign

36 PDSA: Act Determine what modifications should be made in the redesign process Prepare and plan for next test cycle to implement the modifications

37 Continuous Improvement At Miramont, we call the constant change brain damage BUT, we are not burned out, we are burned in. Even our customers are trained to look for what s new at Miramont

38 Respect for all People If there are any problems in quality... any of our employees can pull this switch to stop the production line former Toyota US President Yoshio Ishizaka Hospital equivalent: the Time Out Is there an Ambulatory Equivalent??

39 Ambulatory Checklists

40 Respect for all People The Wisdom of Crowds James Surowiecki The group will give better advice than an expert, or a guess

41 Respect for all People Who knows the weight of the Ox??

42 Respect for all People Who knows the weight of the Ox?? Answer: The crowd knows the weight!!

43 Respect for all People What is the best lifeline??

44 How to Make a Physician Owned Lab (POL) Work in Your Office: Evaluating the Costs and Benefits John L Bender, M.D., FAAFP & Amanda J. Cline, RMA

45 Old Model Physician orders test MA fills out requisition Patient given directions to local lab Patient drives to lab, has test drawn Outside lab runs test Test is reported back to physician next business day MA pulls chart to go with test Physician reviews test, signs it off, and tries to remember what he/she was looking for

46 Old Model, continued MA calls and leaves message on answering machine telling patient that results are in but unfortunately due to HIPAA cannot leave results on machine and patient will now have to call back Patient s spouse hears message, assumes the worst, and calls back three times with an urgent message asking for a return call from physician MA finally makes contact with patient, new medication is ordered, another follow-up visit is scheduled with repeat blood work ordered Receptionist refiles chart. TOTAL TIME: 20 + minutes

47 New Model Physician orders test MA draws patient Test is run in house Result is reported in room to physician and patient Decision is made for new med, result is signed off Patient schedules follow up at check-out Chart is filed TOTAL TIME: 10 minutes

48 Value Added Team We asked the Colorado Foundation for Medical Care to send the Value Added Team ( VAT ) with their stopwatches to measure our patient processing times before and after implementation. We learned that our percent value added time improved from 64.2% to 67.5%, a huge accomplishment considering that our average appointment time increased from 41 minutes in paper to 51 minutes electronically (appendix G). We now track more metrics, spend more time with our patients educating them, and waste less of their time when they are with us. Our online surveys tell us that it is easy for our patients to make appointments 97%

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51 We finally know how many diabetics we have

52 A1C documentation improved over time

53 Managing population metrics for chronic disease is realistic with an EHR

54 External reporting for Fun and Profit Colorado PCMH Pilot Miramont was one of 17 clinics to participate in the Colorado Patient-Centered Medical Home (PCMH) pilot, a joint-venture between HealthTeamWorks and five of the state s major insurance payers to investigate the costs and benefits of the PCMH model in primary care. The pilot program paid PMPM (Per Member Per Month) fees to physician offices and Pay for Performance (P4P) dollars. In 2009 we received over $50, in PMPM payments, $85, for 2010, over $100,000 in 2011, and over $150,000 in The payments continued even after the pilot was complete. DARTNet - In 2010, we enrolled into the national AAFP electronic reporting research program known as DARTNet. We are currently reporting PHQ-9 data and CKD data to University Hospital in Denver, and receive some grant money for doing so.

55 External reporting for Fun and Profit. Medicaid We have grown from 1% Medicaid to 19% Medicaid as a payer source in the last 4 years; Initially receive 10% bonus on our Medicaid children for reporting to the immunization registry and performing ASQ screenings; Now we receive PMPM from regional RCCO (Regional Care Coordination Organizations) and are positioned for P4P and gainsharing next year.

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57 External reporting for Fun and Profit PQRS - We worked with CINA (Clinical Integration Networks of America) to transform our PQRI/PQRS reporting from claims-based reporting through our clearing house to database reporting directly from our SQL server. BTE - Qualified for Bridges to Excellence monies (a recognition program available to us through the Colorado Business Group on Health) for Diabetes and Heart/Stroke metrics. Meaningful Use - We were the first or second practice in the state of Colorado to be paid Stage 1 Meaningful Use monies in May CPCI Two of 73 practices in Colorado awarded, our first payments received in November of 2012, anticipated to be worth over a million dollars over 4 years.

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59 Coaching is Essential to Practice Transformation

60 Miramont University Lean Redesign Concepts Thanks to IPIP Consultant: Richard A. Wright MD. Mph Wright Consulting Professor of Preventive Medicine and Biometrics *Used with permission

61 Why Lean Redesign? Lean Philosophy: Eliminate Waste Waste is disrespectful of humanity because it squanders precious resources. Waste is disrespectful of the employee because it asks them to do work with no value. President of Toyota Waste is disrespectful to patients because it asks them to endure processes or procedures with no value.

62 The value of simple things Waste is everywhere in healthcare if we can harness it, there will be enough left over to care for every man, woman, and child who does not now have access to basic healthcare and we will retain a workforce who finds joy in their work!!

63 So What s Lean Redesign? A system thinking approach to redesigning linked processes called value streams, with the aim of improving efficiency, effectiveness, and overall value of services to the customer

64 Common Problems in Office Practices Long waits to get appointments Long waits to see the provider Long waits on the phone Long waits for lab results Demand exceeds provider capacity Poor clinical outcomes Lean Can Fix These Problems!! 64

65 Lean Achievements 90% reduction in wait times 90% reduction in inventory 100% increase in productivity 50% decrease in defects or errors

66 Lean System Facts Equally True for Health Care In most systems only 5% of processes add value to the customer 35% of processes are necessary but do not add value to the customer 60% of processes are both unnecessary and do not add value Therefore, elimination of waste is a major cost reduction and performance improvement strategy

67 Lean Core Ideas Determine and create value for the customer Achieve one piece flow in the value stream Eliminate the 7 speed bumps (waste) Use a root cause analysis or a proactive method to stop or prevent problems Use data to sustain improvements

68 What Leaders Must Do Create a culture for change Non-blaming environment Transparent communication Team-base engagement Staff empowerment Focus on fixing processes not people

69 Miramont Lean Redesign 4 Tools 1. Root Cause Analysis Tool 2. Value Stream Mapping Tool 3. Cycle time analysis tool 4. 5S Tool

70 Tool # 1 Root Cause Analysis Stop producing errors by stopping production when an error is detected (produce an immediate signal to the location of the error so problem-solving can start immediately. ROOT CAUSE ANALYSIS Manager goes and sees, analyzes, ask why five times By the fifth time, usually find the root cause

71 The Causes of Safety Failures Active failures Hazards Harm System factors

72 The 7 Speed Bumps of Lean Over production Excessive inventory Waiting and delays Unnecessary staff movement Unnecessary service movement Defects or errors Processing

73 Process as a Root Cause 7 Causes of Waste or MUDA

74 Lean Redesign Aphorisms and Mantras 1. Do It Right, Quickly, Safely, and Completely 2. Every System is Perfectly Designed to get the Results it Gets 3. Inefficiencies are usually due to System and Processes rather than People 4. Get Today s Work Done Today Without Yesterday s Work Being in the Way or Stopping the Flow 5. Completely Solve the Customers Problems 6. Do Not Make the Customer Wait

75 Lean Redesign Aphorisms and Mantras 1. Continuous flow increases productivity, profitability, and quality. 2. Customers don't like to wait in line: they are impatient. 3. Errors are opportunities for learning; Errors are golden nuggets to be found not garbage to be buried 4. Continuously solving root problems drives organizational learning and improvement 5. Problems are 20% cause and 80% effect

76 Lean Redesign Method Tool #2: Value Stream Mapping Tool Consultant: Richard A. Wright MD. Mph Wright Consulting Professor of Preventive Medicine and Biometrics

77 What is a Value Stream? Whenever there is a product (or service) for a customer, there is a value stream. The challenge lies in seeing it. - James Womack

78 A Value Stream is the set of all actions (both value added and non value added) required to bring a specific product or service from raw material through to the customer.

79 Potential Value Streams Administrative Processes Office Redesign usually starts here Office Visit Flow Patient Registration Space Organization Telecommunication Information Management Supplies and Inventory Charge, Billing, and Collection Medical Records

80 Potential Value Streams Clinical Processes Patient Scheduling Chronic Care Preventive Care After Hours Medications Diagnostic Tests Provider Paperwork Specialty and Primary Care Referrals

81 How to Use Mapping to Evaluate Value Streams (tool #1) 10 Sequential Steps 1. Train team on use of flow mapping methods and tools 2. Identify the value stream and where it begins and ends 3. Walk the process to identify linked processes 4. Produce the initial value stream map 5. Measure cycle/interval times in the value stream 6. Calculate cycle and TAKT times and other data 7. Walk the process again to identify flow and process-related inefficiencies 8. Produce specific process flow maps to better understand flow and risk points 9. Document process-specific actual or potential risk points 10. Use maps to focus group problem-solving or kaizen event on root causes for risk points

82 There are four symbols and shapes that you will need to be familiar with to diagram your patient process Box Activities, tasks, steps in the process Diamond Decisions Circle Start and end steps Arrow To connect each of the activities, decisions or start and end points

83 Value Stream Map Cycle and Interval Times Patient Visit Stream Patient Enters clinic Patient registered Patient Check-in Patient Sees Provider Patient Check-out Patient Scheduling Diagnostics Goes home Waiting Room Time Waiting Room Time Exam Room Wait Time Exam Room Wait Time Waiting Room Time Waiting Room Time Registration Time Intake Time Provider Time Check out Time Diagnostic Time Cycle Times

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85 TAKT Time (tool #3) Cycle Time Analysis Tool The Pacemaker of One Piece Flow Takt time, derived from the German word Taktzeit which translates to cycle time

86 TAKT Time Calculation Delivery or production time divided by service demand Hours of operation of clinic: 8 hours x 60 min. = 480 min. Total visits per 8 hour period = 100 TAKT time = 4.8 min.

87 Grace Hill TAKT and Interval Times Minutes CYCLE Time TAKE Time Registration Check in Provider Check out Clinic Processes Scheduling Provider time is the only potential constraint in the flow

88 Imbalance in TAKT and Interval Times When Interval Times Exceed TAKT When process interval time exceeds value stream TAKT there is backlog To minimize backlog, the tendency is to pass unfinished work to next process or to speed up and produce errors Solution is to redesign process to decrease interval time or to increase staffing level to meet demand

89 Imbalance in TAKT and Interval Times When Interval Times are Less Than TAKT When process interval time is faster than TAKT Reassign staff to other areas Multitask staff

90 Registration Process Staffing Needs Sample TAKT Analysis 2 FTE actual registration clerks 510 min/day (excluding break time) 52 visits per day TAKT time = 510/52 = 9.8 min per patient Actual Interval time = 2 min per clerk IT/TT = 2/9.8 = 0.2 or 1 required FTEs Conclusion: supply exceeds demand, so there maybe excess staff capacity

91 Sort Straighten Shine Standardize Sustain The 5S of Lean (Tool #4) Method for Standardizing Processes

92 The 5S of Lean (Tool #4) Method for Standardizing Processes

93 Lean Production Cells Method for Creating One Piece Flow Kitchen Example: Sink Trash Refrigerator Micro wave Only One Cook!! Pots & Pans Stove Utensils

94 Process Redesign Pit Falls Don t buy the first answer you get Old habits are hard to break (Culture eats Strategy for breakfast) Don t start a team when you have no data Don t redefine the problem before a team does a root cause analysis Avoid Endless Data Gathering Don t Value stream map before you define the problem area

95 BLAME FREE

96 Future Plans - Keeping Current and Connecting to Others

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99 Phreesia Tablets

100 Teleconferencing in remotely

101 Leveraging New IT

102 Leveraging New IT

103 Build the Medical Neighborhood

104 A Call for Courage Sometimes the opposite of Cautious is not Careless Sometimes the opposite of Cautious is Courage - John L Bender, M.D., FAAFP

105 Xtreme Makeover PCMH edition The Miramont Story Presented by John L Bender, M.D., FAAFP May 4 th, 2013 Sonnenalp, CMS 2013 Spring Conference