Xtreme Makeover PCMH edition The Miramont Story Presented by John - - PowerPoint PPT Presentation

Xtreme Makeover PCMH edition

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

Conflict of Interest Disclosure

John L. Bender, M.D.

Has no real or apparent conflicts of interest to report.

Learning Objectives

John L. Bender, M.D. Recognize how NCQA recognition makes it possible to improve safety, efficiency, patient

• utcomes 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)

Our story begins….

2002 in Fort Collins Colorado…. 2002 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

In a basement, paneling on the walls

Walls of Paper Charts

Move that Bus!!!

Our story today…

2013 in Larimer County Colorado….

• 4 locations in 3 separate communities
• Open M-F 8-8, Saturdays 9-1
• 16 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

4th fastest growing company in Northern Colorado

Miramont’s Growth Curve

year receipts volume 2001 $169,000.00 2002 313,565.00 2003 428,876.00 2004 494,264.00 2005 559,110.00 2006 845,298.00 2007 1,449,348.00 2008 1,940,499.00 2009 2,616,000.00 2010 3,505,440.00 2011 4,356,230.00 2012 4,804,885.00

Miramont's Growth as measured by receipts

500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 4,500,000 5,000,000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

year receipts volume 2001 $169,000.00 2002 313,565.00 2003 428,876.00 2004 494,264.00 2005 559,110.00 2006 845,298.00 2007 1,449,348.00 2008 1,940,499.00 2009 2,616,000.00 2010 3,505,440.00 2011 4,356,230.00 2012 4,804,885.00

2010 HIMSS Ambulatory Award

2011 Colorado PCMH of the Year

34 primary care physicians leave practice during the same time

8 are bankruptcies…

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

• wned medical group (600 total

physicians in the county)

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.

Wanting to get out of last century…

Company Retreat August 2007

Ambulatory Medicine Needs to Have a Vision

• “Where there is no vision,

the people perish”

Proverbs 29:18

Positioning Statement:

• “For local families desiring

healthcare, Miramont Family Medicine is the choice that offers the most convenience and the highest value”

Miramont Mission Statement –

“to deliver compassionate, modern, timely healthcare in a clean, professional environment that promotes patient and staff growth, health, and happiness”

“The Restaurant with Bad Food”

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

$1.4 million in new building in 2005

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

Every Year We Bring New Products and Services

• 2009 Patient Centered Medical Home, New Website, patient portal,
• nline 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, email blast marketing to patient base, automated collections calls

• 2011DME sales, drive through pharmacy, fluoride dental treatments for

children

• 2012 4th location in Parker Colorado, self check in kiosks, Phreesia

tablets, Medtronics Insulin pumps, iPro

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

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

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

 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!!

PDSA: Action Plan

State specific tasks to achieve each

• bjective

State who will do these tasks State timelines for completing tasks

Who is accountable for getting things done!!

PDSA: Do

 Select qualitative and quantitative measures

 Complete analysis of measures  Compare results with baseline values  Summarize and reflect on what was learned from the data

PDSA: Study

PDSA: Study

 Performance Measures Linked to Project Aims  Types of Measures:

 How Well (efficiency)  Impact (outcome)

PDSA: Study

“If you do not measure, you will not sustain redesign”

Determine what modifications should be made in the redesign process Prepare and plan for next test cycle to implement the modifications

PDSA: Act

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…”

Respect for all People

• “If there are any problems in quality . . . any
• f 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??

• Ambulatory

Checklists

Respect for all People

• The Wisdom of Crowds – James Surowiecki
• The group will give better advice

than an expert, or a guess

Respect for all People

• Who knows the weight of the Ox??

Respect for all People

• Who knows the weight of the Ox??
• Answer: The crowd knows the weight!!

Respect for all People

• What is the best lifeline??

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

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…

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

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
• ff
• Patient schedules follow up at check-out
• Chart is filed
• TOTAL TIME: 10 minutes

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%

We finally know how many diabetics we have

A1C documentation improved

• ver time

Managing population metrics for chronic disease is realistic with an EHR

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 $50,000.00 in PMPM payments, $85,000.00 for 2010, over $100,000 in 2011, and

• ver $150,000 in 2013. 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.

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.

External reporting for Fun and Profit

• PQRS
• We worked with CINA (Clinical Integration Networks of

America) to transform

• ur

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 2011.

• CPCI

– Two of 73 practices in Colorado awarded, our first payments received in November of 2012 , anticipated to be worth over a million dollars

• ver 4 years.

Coaching is Essential to Practice

Transformation

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

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.

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!!

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!!

Lean Achievements

• 90% reduction in wait times
• 90% reduction in inventory
• 100% increase in productivity
• 50% decrease in defects or errors

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

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

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

Miramont Lean Redesign “4 Tools”

• 1. Root Cause Analysis Tool
• 2. Value Stream Mapping Tool
• 3. Cycle time analysis tool
• 4. 5S Tool

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

The Causes of Safe The Causes of Safety F ty Failures ailures

Active failures System factors Hazards Harm

The 7 “Speed Bumps” of Lean

• Over production
• Excessive inventory
• Waiting and delays
• Unnecessary staff movement
• Unnecessary service movement
• Defects or errors
• Processing

Process as a Root Cause

7 Causes of Waste or MUDA

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

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

• rganizational learning and improvement

5. Problems are 20% cause and 80% effect

Lean Redesign Method

Tool #2: Value Stream Mapping Tool

Consultant: Richard A. Wright MD. Mph Wright Consulting Professor of Preventive Medicine and Biometrics

“Whenever there is a product (or service) for a customer, there is a value stream. The challenge lies in seeing it.”

• James Womack

What is a Value Stream?

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.

Potential Value Streams

Administrative Processes

• Office Visit Flow
• Patient Registration
• Space Organization
• Telecommunication
• Information Management
• Supplies and Inventory
• Charge, Billing, and Collection
• Medical Records

Office Redesign usually starts here

Potential Value Streams

Clinical Processes

• Patient Scheduling
• Chronic Care
• Preventive Care
• After Hours
• Medications
• Diagnostic Tests
• Provider Paperwork
• Specialty and Primary Care Referrals

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

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

There are four symbols and shapes that you will need to be familiar with to diagram your patient process

Value Stream Map

Cycle and Interval Times

Patient Enters clinic Patient registered Patient Check-in Patient Sees Provider Patient Scheduling Diagnostics Goes home

Cycle Times

Registration Time Waiting Room Time Intake Time Provider Time Check out Time Diagnostic Time

Patient Visit Stream

Patient Check-out

Waiting Room Time Exam Room Wait Time Exam Room Wait Time Waiting Room Time Waiting Room Time

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

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.

Grace Hill TAKT and Interval Times

0.0 5.0 10.0 15.0 20.0 R e g i s t r a t i

• n

C h e c k i n P r

• v

i d e r C h e c k

• u

t S c h e d u l i n g Clinic Processes Minutes CYCLE Time TAKE Time

Provider time is the only potential constraint in the flow

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

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

Staffing Needs

Sample TAKT Analysis

• Registration Process

– 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

The 5S of Lean (Tool #4)

Method for Standardizing Processes

• Sort
• Straighten
• Shine
• Standardize
• Sustain

The 5S of Lean (Tool #4)

Method for Standardizing Processes

Lean Production Cells

Method for Creating One Piece Flow Kitchen Example:

Trash Stove Micro wave Refrigerator Sink Pots & Pans Utensils Only One Cook!!

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

BLAME FREE

Future Plans - Keeping Current and Connecting to Others

Phreesia Tablets

Teleconferencing in remotely…

Leveraging New IT

Leveraging New IT

Build the Medical Neighborhood

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

Xtreme Makeover PCMH edition

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