Work Design and Value Stream Mapping Jane Brock, MD, MSPH Colorado Foundation for Medical Care May 4, 2013 This material was prepared by the Colorado Foundation for Medical Care (CFMC), the Integrating Care for Populations & Communities National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. PM-4010-106 CO 2013 2 1
PMPM Shared savings PQRS Care Coordination payment 2
Epic Whole Practice Reimagination Continuous unrelenting process of change Replacing old patterns and processes with new ones Changed sense of identity Transformation is a local process Learn to be a learning organization Nutting et al. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med 2009;7:254-260. Value Stream Mapping A technique for analyzing and designing the flow of materials and information required to bring a product or service to a consumer. From supplier to customer Visualize and understand An exercise in insight.. 3
Producer Product Process PRODUCER = Time/Motion An activity which takes a worker away from the place where he/she adds value 4
Main purpose to remove wasteful activity from somebody s job Advantages The best recruiting tool you can imagine Promotes awareness of team/roles It s fun and interesting Disadvantages Resource intensive Measure % time spent per activity of interest # interruptions/hr Task switches/patients seen How to measure work by observation Determine essential functions* Decide what is observable Decide an interval or specific task set Get a stopwatch and a pad of paper Write down what you see Can ask for clarification 5
Essential functions for MDs Making patient management decisions Writing prescriptions Maintaining the medical record Providing patient education Assigning charges Chatting Observable physician tasks History Medication reconciliation Examination Education/advice Reading/Writing in the medical record Chatting Interruptions Task switches* Personal/other Count Events Direct patient care 6
Direct patient care 38 55% Charting 35 50% Not physician work 26 43% Interruptions Patient switches 3-11/hr 1.5 3x schedule When/Why might you use this? Restructure roles using data Empower staff/maintain buy-in Examine outliers Protect key activities Reduce task switching Get some a-ha level insight into YOUR job structure.. EXAMPLE: Establish ground rules for interruption 7
5/13/13 Product = Patient ValueAdded Time Because waiting is harmful.. Main Purpose = outcome measure Advantages Everyone agrees - teambuilding Easiest Great balancing measure when testing changes Disadvantages Might be too broad for a truly dysfunctional practice Measures % Value-Added Time (VAT) Time for each step Wait time between steps 8
Components of a visit Check in MA activities Physician visit Check out Total time per segment Variability How to Observe Patient Flow Identify key steps Check in Nurse/MA evaluation Physician/provider evaluation Check out Measure from patient arrival to departure Key steps The interval between Measure about 10 pts Plot/graph for usefulness 9
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3.1 5.1 15.2 2.2 3.6 6.1 7.9 8.6 8.5 1.4 3.9 5.1 4.3 11
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How might you use this? Variation!! By task By provider Best/worst cases for further dissection Balancing measure for change initiatives Track improvement over time Engage patients in process improvement How might you use this? EXAMPLES: Are you more efficient with late arrivals? Is longer MA time associated with better VAT? 13
PROCESS Advantages Can be done by interview Produces the fastest results Disadvantages Not as interesting for the observation team! Can involve fewer people contribute to silo d activity perspective Measures Staff satisfaction Number of call-backs MA hold stack How to Map a Process Interview process owners Identify key steps including start and finish Use the ideal order Draw a simple flow diagram Observe for variation* Add points of variation Present to others for tweaking 14
1181 visits to 66 primary care practices in Co Practice Characteristics N Percent EHR in use Yes 13 20 No 53 80 Number of providers 1-3 15 23 4-6 25 38 7-9 14 21 10 or more 12 18 Specialty Family Medicine 58 88 Internal Medicine 8 12 Average appointment duration 47 (mins) Average time waiting 19 Time for initial physician evaluation 14.7 25% with MD f/u 16.0 Waiting for MD 8.4 Waiting for MA/nurse 7.8 Results VAT (%) P-value EHR Yes 62.5 0.04 No 57.1 Practice size (# providers) Less than 3 0.0005 Arrival time On time 64 <.0001 Late (> 5 mins) 61% Early (>10 mins) 57% 15
As for process workflows.. 2013 A Crucial Year For Quality Reporting and Electronic Health Record Adoption 2013 The American Academy of Family Physicians estimates that participating in these initiatives (PQRS, MU) this year could save a physician $19,000 in avoided penalties 16
If you would like assistance with PQRS data collection and reporting.. We do free consultations and assistance for CardioData and PQRS data submission We have a weekly newsletter where you can find information on free educational webinars, several E.H.R user group calls/webinars/advanced training Devin Detwiler: ddetwiler@cfmc.org It all comes down to what data do you need and who should collect it 17
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