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
P DSA: 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!!
P D SA: 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!!
PD S A: 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
PD S A: Study PD S A: 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”
PDS A : Act Determine what modifications should be made in the redesign process Prepare and plan for next test cycle to implement the modifications
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 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??
• 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 off • 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 over 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 over $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 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 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 over 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
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
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 Hazards System factors 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 organizational 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
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
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 Redesign usually starts here • Office Visit Flow • Patient Registration • Space Organization • Telecommunication • Information Management • Supplies and Inventory • Charge, Billing, and Collection • Medical Records
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
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
Value Stream Map Cycle and Interval Times Patient Visit Stream Patient Patient Patient Patient Patient Sees Patient Enters Scheduling Goes registered Check-in Provider Check-out clinic Diagnostics home Exam Waiting Exam Waiting Waiting Room Waiting Room Room Room Room Wait Room Time Wait Time Time Time Time Time Diagnostic Registration Check out Intake Provider Time Time Time Time Time Cycle Times
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 20.0 Minutes 15.0 CYCLE Time 10.0 TAKE Time 5.0 0.0 r n g n t e u i n o d o k i i i l t v c u a k e o d r c r t h e e s P C h i h g c C e S R Clinic Processes 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: Sink Trash Refrigerator Micro Only One Cook!! wave Pots Utensils & Stove Pans
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
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