The Lean Paradox: Time and Other Dimensions in Healthcare Quality

The Lean Paradox: Time and Other Dimensions in Healthcare Quality Production & Operations Management Annual Meeting Reno, NV, April 29, 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: http://www.outcomesmhcd.com/pubs/publications.htm POMS-2011 2011 Linda LaGanga 1

What s it all about? Healthcare Delivery Systems Configure Deliver Measure Improve The Continuum of Healthcare Lean Transition from Inpatient to Outpatient Settings Timeliness in Access to Care The Lean Paradox POMS-2011 Linda LaGanga 2

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. POMS-2011, Linda LaGanga 3

The 2 Dimensional Continuum of Healthcare Physical Health Inpatient Services / Emergency Department Outpatient Services Mental Health / Behavioral Health POMS-2011, Linda LaGanga 4

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 Enhance funding Streamline documentation Coordinate care POMS-2011, Linda LaGanga 5

Coordinated and Integrated Healthcare Services Example of a Lean Improvement Project and the Continuum of Care 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 POMS-2011, Linda LaGanga 6

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 POMS-2011, Linda LaGanga 7

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. POMS-2011, Linda LaGanga 8

Configuration of Appointment Allocation System Supplier Clinical Intake Teams Access Center Customer Consumers Seeking Access Release appointments to days of the scheduling week Receive call from consumer Check appointment inventory for availability Consumer not admitted. Exits but may call again. Monday Inventory of Tuesday Appointments No slots available or no appropriate match for consumer Wednesday Thursday Match consumer to appointment slot and remove appointment from inventory of available appointments Consumer given an Intake appointment. Consumer exits, waits for Intake appointment. Friday POMS-2011, Linda LaGanga 9

Consumers Intake Process: Before Lean Improvement Orientation Orientation Orientation Orientation Providers 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 noshows Exit: Completed Intakes POMS-2011, Linda LaGanga 10

Intake Process: After Lean Improvement Consumers Providers Orientation Overbooked consumer who shows up Individual Intake Assessment Individual Intake Assessment Individual Intake Individual Assessment Intake Assessment Clinician called into service for overbooked consumer who showed up POMS-2011, Linda LaGanga 11

Intake Process Before and After Consumers Providers Consumers Providers Orientatio n Orientatio n Orientatio n Orientatio n Delay (Days) Individual Intake Individual Assessme Intake Individual ntassessme Intake ntassessme nt Idle Intake Clinician due to consumer noshow Consumer leaves and doesn t return Idle Intake Clinician due to consumer noshow Overbooked consumer who shows up Orientati on Individu alindividu Intake Assess Intake alindividua ment Assess Intake l ment Assess Intake ment Assess ment Clinician called into service for overbooked consumer who showed up Delay (Days) Consumer leaves and doesn t return Individual Psychiatri Individual c Psychiatri Evaluation c Evaluation Idle Psychiatrists due to consumer no-shows Exit: Completed Intakes POMS-2011, Linda LaGanga 12

Appointments scheduled and no show rates before and after lean improvement 500 400 300 200 100 0 Appointments Scheduled Mon Tue Wed Thu Fri Before After 20% 15% 10% 5% 0% No-Show Rates Mon Tue Wed Thu Fri Before After POMS-2011, Linda LaGanga 13

Improvement in accessibility and timely access to services based on service value in lean outpatient health care (based on Womack and Jones, 2005). Before Consumer s steps and time for admission to services, before lean process improvement. Time Step likely to recur? 1. Call Access Center for admission to services. 10 minutes Yes 2. No slot available. Wait to call again. 3 days 1 week Yes 3. Call Access Center for admission to services. 10 minutes 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. Appropriate slot obtained. Appointments made for orientation and intake assessment. 30 minutes. No 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 4 th call) 5 weeks 245 minutes Actual clinical service time (value creating time) 60 90 minutes Total steps with recurrent steps POMS-2011, Linda LaGanga 14 14

Improvement in accessibility and timely access to services after Lean Improvement Consumer s steps and time for admission to services, after lean process improvement. 1. Call Access Center for admission to services. 10 minutes Yes Time Step likely to recur? 2. No slot available. Wait to call again. 1 3 days Yes 3. Call Access Center for admission to services. 10 minutes 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 3 rd call) 1 week + 190 minutes Actual clinical service time (value-creating time) POMS-2011, Linda LaGanga 70-100 minutes 15 Total steps with recurrent steps 12

Comparing process time and steps: 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 4 th call) = 3 x (25 minutes + 1 week) + 30 minutes + 1 week + 50 minutes + 1 week + 90 minutes = 5 weeks + 245 minutes = 5 weeks 4 hours and 5 minutes Total steps with recurrent steps (worst case with 3 instances of steps 4 and 5) = 3 x 3 + 5 = 14 POMS-2011, Linda LaGanga 16

Comparing process time and steps: After 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 3 rd call) = 2 x (25 minutes + 3 days) + 30 minutes + (3 days + 10 minutes) + (1 day + 40 minutes) + 90 minutes = 7 days + 190 minutes = 1 week 3 hours and 10 minutes Total steps with recurrent steps (worst case with 2 instances of steps 4 and 5) = 2 x 3 + 6 = 12 POMS-2011, Linda LaGanga 17

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 POMS-2011 Linda LaGanga 18

What is the Lean Paradox? Just in time? NO New Bottlenecks? YES Rapid Improvement? NOT! Solutions Clear out project clutter Prioritize Realign project scheduling POMS-2011, Linda LaGanga 19