Presenters Lean Healthcare Outcomes: Delivering Results John Duggan Director of Real Estate Operations & Retail Subsidiaries Reliant Medical Group, Worcester, MA C01: October 2nd, 2012 Marc Margulies AIA, LEED AP Margulies Perruzzi Architects, Boston, MA Learning Objectives 1. LEAN design process for collaboration between clinicians, facilities professionals, and patients 2. Efficiency in clinical environments 3. Financial models of patient-centered medical home centers and urgent care centers 4. Building Information Modeling (BIM) in the design process Reliant Medical s Lean Process
OVERVIEW KAIZEN AGENDA 40,000 sf multi-disciplinary clinic Family Practice served 12,000 patients, going to 15,000 The term medical home refers to an innovative healthcare delivery method providing patients with a team of healthcare professionals, rather than one doctor, who educate, monitor, guide and reach out. Pilot project for 19 clinics Clinical staff of 24 Started October 2009 Week 1: Week 2: Week 3: Week 4: Week 5: The Visit (check-in through check-out) (A) Telephone (B) In-basket management Level-loading provider schedules (A) Management (B) Space Population (patient) management VALUE STREAM MAPPING (VSM) CURRENT VS. FUTURE STATE CURRENT STATE # of steps: 16 Visit Duration: 64:30 Patient Care Time: 32:30 Wait Time: 32:00 FUTURE STATE # of steps: 12+4=16 Visit Duration: 42:00 Patient Care Time: 33:00 Wait Time: 9:00
CURRENT STATE DEMAND FUTURE STATE LOOPS PRE-VISIT/SCHEDULING VISIT POST-VISIT/BETWEEN VISITS UNMET DEMAND 1118 Avoidable ER Visits 728 UC Visits 1300 IM APs Improve access Improve team effectiveness & establish/sustain and Lean culture Decrease patient wait time Improve follow-up & population management INITIAL STRATEGY PRE-KAIZEN ISSUES & ROOT CAUSES Exam Room Exam room layout Non-standard rooming process Completed time observations of the greet, rooming, MA visit/treatment and Nurse visit/treatment process, Checkout Completed Spaghetti Charts of the process Identified Issues Identified Root Causes Develop and prioritize Countermeasures Patient Injection Workflow Limited parallel processing and std work Layout No dedicated nurse for injections Checkout On hold for other referrals Work excuse note slows check out process Communication Unable to locate team members Providers walking to nursing call center to communicate with nursing staff Wireless Exam rooms losing internet connectivity, therefore Epic goes down
COUNTERMEASURES Establish standard work for rooming, pre-visit form, excuse notes, injection standard work, patient returning from in-visit lab, past pass check out Define/implement room occupancy/need by use of flags, lights, beepers Co-locate similar equipment, ie. refrigerator, sink, cabinets, and nurses, 5S the refrigerator Include patient chart activation option as part of rooming and check-out standard work INJECTION STANDARD WORK PRE-KAIZEN POST-KAIZEN Exam Room of the Future Video
KAIZEN SUCCESS SPAGHETTI DIAGRAMS KEY MEASUREMENT START TARGET END DIFFERENCE % IMPROVEMENT WAIT TIME Exam room wait time 17 mins 5 mins* 12 mins 5 mins 29.40% Check out wait time 2 mins, 20 secs by 25% 1 min, 52 secs 28 secs 18.70% Process completeness & accuracy 57.60% 75% TBD TBD TBD EXISTENCE OF STANDARD WORK Greeting N Y Y NA NA Room Prep N Y Y NA NA Rooming N Y Y NA NA MA/Nurse Visit** N Y Y NA NA Fast Pass Check out N Y Y NA NA Check out work content 5 mins by 25% by > 15% by > 15% by > 15% DESIGN CRITERIA AND WEIGHTS SCHEME 5 VIEW (SCREENSHOT) Weight 1. VISUAL MANAGEMENT Patients view 3.5% View of Exam Rooms 3.5% View of Waiting Rooms 3.5% Practitioners View 3.5% Nurses View 3.5% MA's View 3.5% PSS (Check-in/out) View 3.5% Overall visual controls/line of site 5.0% Team Communications 3.5% Medical Home/Huddle Room 2.0% SUBTOTAL 35% 2. FLOW Patients 7% Providers 7% Nurses 7% MA's 7% PSS 7% SUBTOTAL 35% 3. EXPANSION CAPABILITY Accommodate growth (2 provider FTE's 10% with 2:1 exam/prov room ratio) 4. COST 20% TOTAL 100%
SCHEME 6 VIEW (SCREENSHOT) SCHEME 6 VIEW (SCREENSHOT) DESIGN CRITERIA AND WEIGHTS COMPLETED PROJECT 1. VISUAL MANAGEMENT WEIGHT SCHEME 5 SCHEME 6 Patients view 3.5% 1 4 View of Exam Rooms 3.5% 2 4 View of Waiting Rooms 3.5% 1 4 Practitioners View 3.5% 2 4 Nurses View 3.5% 2 5 MA's View 3.5% 2 5 PSS (Check-in/out) View 3.5% 3 5 Overall visual controls/line of site 5.0% 1 5 Team Communications 3.5% 3 5 Medical Home/Huddle Room 2.0% 3 2 2. FLOW SUBTOTAL 35% 0.72 1.69 Patients 7% 4 4 Providers 7% 2 4 Nurses 7% 4 4 MA's 7% 3 5 PSS 7% 4 4 35% 1.19 1.47 SUBTOTAL 3. EXPANSION CAPABILITY Accommodate growth (2 provider FTE's 10% 2 5 with 2:1 exam/prov room ratio) 0.2 0.5 4. COST 20% 4 3 0.8 0.6 TOTAL 100% 2.91 4.26
PLAN. DO. CHECK. ACT. This is 6 weeks of work in 4 days. RESULTS IMPLICATIONS FOR PATIENTS Many just do it projects Greater standardization of work Scheduling guidelines (Wave Scheduling, huddles, etc.) Re-design of space (spill-over ) Inter-departmental communications (additional time slots ) Improved Visual Management Better access to appropriate clinical care Less waiting time (reduced 50%) Patient satisfaction up 11.3% Improved telephone coverage Decreased # of lines of transcription
How much did Lean cost to date? 2007-2009 2010 2011 YTD 2012 TOTAL TOTAL SALARIES $449,823 $269,118 $430,678 $125,381 $1,275,000 LEAN CONSULTANTS $139,221 $260,859 $45,597 $27,902 $473,579 SUPPLIES $155,854 INITIAL TRAINING $20,000 Survey 400 people in primary care including providers, managers, and staff About 152 (~38%) responded TOTAL EXPENSES $1,924,433 But Reliant was able to realize a 29% increase in patient volume and profitability within the same facility footprint. What is your overall assessment of the impact of Lean to your department? Could we have improved the process of bringing PCIS to your clinical area?
Do you see PCIS and Lean as having potential for continuing improvements in our care delivery? Would you prefer to return to more traditional management and culture? Phone Abandonment Rate Adult and Pedi Primary Care Objective Measures 15.00% 14.00% 13.00% 12.00% 11.00% 10.00% 9.00% 8.00% 7.00% 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% 110,572 116,775 105,493 103,734 109,443 113,498 100,983 99,318 42 9 118,961 102,840 108,827 Primary Care Volume vs Abandonment Rate 111,066 99,122 42 9 29.6 25 44.4 74 1 74 1 85 2 33 3 44.4 51. 81 5 77 8 131,446 120,760 120,940 123,049 117,888 112,959 109,301 66 7 73 3 60 86.7 70 0 86 140,000 120,000 100,000 80,000 60,000 40,000 20,000 0 Volume Abandonment Rate Most Sites Transformed
35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% No Show Rate Radiology - FY2011 Kaizen Events JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC GSB MMG GSB U/S GRO MMG GRO U/S Linear (GSB MMG) Linear (GSB U/S) Linear (GRO MMG) Linear (GRO U/S) 25 20 15 10 5 0 Access in Radiology FY2011 Kaizen Events SCR MMG Dx MMG Dx MMG Combo U/S Rad Monitored U/S Un monitored Linear (SCR MMG) Linear (Dx MMG) Linear (Dx MMG Combo) Linear (U/S Rad Monitored) Linear (U/S Un monitored) Improvement on Total Average Wait Time Improvement on Would Recommend Practice 70% 20% 20% Percent Improvement on "Would Recommend Practice" 60% 15% 50% 40% 30% Percent Improvement 10% 5% 5% 20% 0% FIT FP LEO Pedi MAY IM MLF IM MLB Pedi Primary Care Department *Sites listed above demonstrated sustained improvement over time. *Sites listed above demonstrated sustained improvement over time.
Number of Suggestions Implemented Since October 2011 Participation in the Annual Morehead Survey Increasing Domain RMG 2009 RMG 2010 RMG 2011 Participation rate 60% 72% 86% No. of people responding (Clinic Ops) Workforce Commitment Percentile ranking* 654 780 970 49 th 39 th 63rd * Based on Morehead s National Healthcare database