results focused process driven ambulatory clinic …...results focused process driven ambulatory...

Kim Carli and Doug Stahl, 6.16.2016

RESULTS FOCUSEDPROCESS DRIVEN AMBULATORY CLINIC REDESIGN

Learning Objectives

• Recognize how the alignment of Lean and Clinical Business Intelligence (CBI) initiatives can help organizations build the skills and experience required for continuous performance improvement

• Apply integrated Lean and CBI principles in an ambulatory care environment

• Discuss lessons learned from the design and implementation of a model cell to improve outpatient access and experience

About City of Hope

• Founded in 1913 as a tuberculosis (TB) sanatorium

• Beckman Research Institute established in 1983

• NCI-designated Comprehensive Cancer Center

• Founding member, National Comprehensive Cancer Network

• 215 beds, ~6,000 IP cases and 211,000 OP visits per year (2015)

• Community Practice Sites expanding: Antelope Valley, Corona, Pasadena, Santa Clarita, Simi Valley, Mission Hills and Palm Springs

About City of Hope

• Among the first to perform bone marrow transplantation (BMT); now one of the world’s largest, most successful programs

• Third-largest breast cancer program in California

• Over 400 clinical trials enrolling more than 6,000 patients annually

• National philanthropy raises more than $100 million each year

• Millions benefit from scientific and medical advances developed from City of Hope technologies

– synthetic human insulin, human growth hormone, Rituxan, Avastin, Erbitux and Herceptin

• COH Lean journey has been underway for approximately seven years

• COH CBI journey began informally four years ago and was formally announced in Feb. 2013

Origins of Our Philosophy and Perspectives

Providence Little Company of Mary, Torrance, CA

Regina Qu’Appelle Health Region – Regina, Saskatchewan, Canada

Akron Children’s Hospital – Akron, OHAtrius Health – Boston, MABJC Healthcare -St. Louis, MOBloodCenter of Wisconsin – Milwaukee, WIBronson Healthcare – Kalamazoo, MICarolinas HealthCare System – Charlotte, NCChristie Clinic – Champaign, ILCleveland Clinic – Cleveland, OHExeter Health Resources – Exeter, NH*Gundersen Health System – La Crosse, WIHealthEast Care System – St. Paul, MNHennepin County Medical Center – Minneapolis, MNHenry Ford Health System – Detroit, MIHonorHealth – Phoenix, AZ*Inova Health System – Falls Church, VAIntermountain Healthcare – Ogden, UT*Johns Hopkins Medicine – Baltimore, MDLee Memorial Health System – Cape Coral, FL*Lehigh Valley Health Network – Allentown, PAMartin Health System – Stuart, FLMartin’s Point Health Care – Portland, MEMayo Clinic Health System-Franciscan Healthcare – La Crosse, WI*McLeod Health – Florence, SCMemorialCare Health System – Fountain Valley, CAMercy Health System – Chesterfield, MONemours – Jacksonville, FLNew York Health and Hospitals Corporation – New York, NYOrlando Health – Orlando, FLPalo Alto Medical Foundation – Palo Alto, CAParkview Health System – Fort Wayne, IN

HVN Members

Henry Ford Health System – Detroit, MILee Memorial Health System – Cape Coral, FL Martin Health System –Stuart, FLMemorialCare Health System – Fountain Valley, CAPalo Alto Medical Foundation – Palo Alto, CASalem Health – Salem, OR Southern Illinois Healthcare – Carbondale, ILStanford Children’s Health – Palo Alto, CA*ThedaCare – Appleton, WITucson Medical Center –Tucson, AZ

Both Networks

CBIN Members

•Aspirus: Wausau, WI•Bellin Health Care Systems: Green Bay, WI•Boulder Community Hospital: Boulder, CO•City of Hope: Duarte, CA

•Henry Ford Health System, Detroit, MI•Hospital for Sick Children: Toronto, ON, Canada•Lee Memorial Health System: Ft Myers, FL•Martin Health System: Stuart, FL•MemorialCare Health System: Fountain Valley, CA•Munson Health System: Traverse City, MI•New Hanover Regional Medical Center: Wilmington, NC•Palo Alto Medical Foundation: Palo Alto, CA•Salem Health: Salem, OR•Southern Illinois Healthcare: Southern IL•Stanford Children’s Health: Palo Alto, CA•ThedaCare: Appleton, WI•Tucson Medical Center: Tucson, AZ

Presbyterian Healthcare Services –Albuquerque, NMRichard L. Roudebusch VA Medical Center –Indianapolis, INSalem Health – Salem, ORSan Francisco General Hospital, San Francisco, CASaskatoon Health Region – Saskatoon, Saskatchewan, CanadaSeattle Cancer Care Alliance – Seattle, WASeattle Children’s Hospital – Seattle, WASouthern Illinois Healthcare – Carbondale, ILSpectrum Health System – Grand Rapids, MI*St. Boniface General Hospital – Winnipeg, Manitoba, CanadaSt. Joseph Health System – Orange, CASt. Joseph Regional Health Center – Bryan, TXSt. Mary’s General Hospital – Kitchener, Ontario, CanadaStanford Children’s Health – Palo Alto, CAStanford Hospital & Clinics – Stanford, CASutter Health Central Valley Region – Modesto, CA*ThedaCare – Appleton, WITucson Medical Center – Tucson, AZUMass Memorial Health Care – Worcester, MA*University of Michigan Health System – Ann Arbor, MIUniversity of New Mexico Health System –Albuquerque, NMValley Health – Winchester, VAWellSpan Health – York, PAWinona Health – Winona, MN

Simultaneous (Lean + CBI): Guiding Principles

• CBI isn’t an end, it’s a means to a performance improvement end

– an enabler for continuous performance improvement

• Mindset, Skillset, Toolset – in that order

• The Lean Startup as a reference model for CBI program development

COH Dashboards,

Scorecards

and KPIs

COH Dashboards,

Scorecards

and KPIs

COH Dashboards,

Scorecards

and KPIs






CBI Framework: Mindset > Skillset > ToolsetInterdependent Components, and Sequence Matters…

Mindset Skillset Toolset

The culture of your

organization is:

• Evidence based

• Data driven

• Process oriented

• Transparent

• Collaborative

Your staff is

proficient in:

• Applying scientific thinking to their work

• Using Visual Management

Tools and

Technology:

• Have been deployed based on organizational needs, rather than what vendors can offer






The Lean Startup

• Recommended by two colleagues:

– a Lean Sensei

– a CBIN member

• What’s a Lean Startup?

– “an organization dedicated to creating something new under conditions of extreme uncertainty”

– can be small or large

– “what they all have in common is a mission to penetrate the fog of uncertainty to discover a successful path to a sustainable business”

The Minimum Viable Product (MVP)

• What’s a Minimum Viable Product (MVP)?

– The smallest and / or fastest prototype you can create and deploy to visionary early adopters

• Contrary to long development and testing periods that strive for product perfection before initial deployment

– Helps entrepreneurs start the Build-Measure-Learn feedback process as quickly as possible

• What do customers really care about?

• Avoid building products and features that nobody wants

• MVP Hypothesis

– Process delivers a big vision in small increments

• Visionary adopters will “fill in the gaps” on missing features if the MVP solves a real problem

– Any effort beyond what is required for a MVP is considered waste because it wasn’t driven by a response to the marketplace


AMBULATORY CLINIC REDESIGN: CALL TO ACTION

Initial Observation (Q2 2014):New patient visits are not converting to ‘treatments’

Integrated Access

Team (IAT)

• Launched on 7/31/14 to identify and

minimize conversion barriers in the patient access pipeline

Where are the real constraints?

Patient-Centric Ambulatory Operating Model:What we need…

Coordinated efforts and clearly defined interfaces between functions

Patient-Centric Ambulatory Operating Model:What we have…

Poorly coordinated efforts and unclear interfaces

Patients must navigate between functions

Patient-Centric Ambulatory Operating Model:What we really have…

Patients and Staff must navigate through a maze of different people, processes and technologies:

- within each function

- between and among functions

Women’s Center Model Cell Mandate: Improve Access and Experience


CALL CENTER PERFORMANCE IMPROVEMENTS

Call Center Reason for Action

• Telephone interactions are a central part of every patient’s City of Hope experience.

– It is impossible to achieve and sustain an outstanding patient experience without a best in class contact center.

• Failure to improve this component of our patient experience will result in:

– Decreased market share (and loss of patient care revenue)

– Increased patient frustration and dissatisfaction

– Increased reputational risk (and loss of income from philanthropy)

– Real and perceived care coordination concerns

• AIM: Consistently deliver a best-in-class contact center experience as measured by all applicable internal and external reference criteria.

– Call Center Service Level >=80%

– Patient Satisfaction with “Ease of Reaching Office Staff by Phone” = 90th

percentile

Voice of The Customer (VOC)

“ I had to learn 10-15 COH telephone numbers so I could care for my son.”

- Parent / Caregiver of a Current Patient

“ I waited for long periods of time, up to an hour on hold, to verify my appointment

time, date and physician. I was given a phone numbers for medication related

triage - it was disconnected.”

- COH Employee and Recent Patient

“I was referred to the new patient department after three calls. The phone system

is not friendly and people I encountered along the way were not pleasant to deal

with…”

- Recent New Patient Comments

Someone called the main Medical Center (Duarte) and was told a particular

physician does not work for City of Hope. The physician works at our Pasadena

office.

Ease of Reaching Office Staff by Phone:Where we started (July 2014, 16th percentile)…

Call Centers: Pre BI / PI Alignment

• Monthly summary report produced in tabular format and distributed via e-mail

• Some users also access daily and intraday call detail reports – not widely available

• No forum for review or improvement

Call Centers: Post BI / PI Alignment

• Facilitator works with customers to develop MVPs and refine visual reports

• More meaningful, compelling visuals created and delivered weekly to managers who have been trained to use them

• Facilitates rapid identification of performance improvement opportunities

Call Center Service Levels: Performance Improvement Summary

7/14/2014First Week of Measurement

Service Level Increased from 54% to 77% in Eight Weeks

Call Center Service Levels: Then and now…

Recent Update:Week of 5/2/2016

2015 – 2016: Performance Improved and Sustained

Lean Process Improvement Efforts

• Performance Measurement and Management

– Regular staff review of performance against KPIs

• Leader Standard Work

– Call Quality Audits

• Staffing Improvements

– increased service hours, distributed breaks, cross-coverage among teams

• Standard Work Development

• Training (skills matrix)

Cross Coverage ExperimentMedical Oncology & Surgery Call Centers

• First experiment produced higher efficiency but lower effectiveness (more calls answered, but not necessarily answered “well” by the “other” team)

• Analysis of lessons learned resulted in co-development of standard work,documented in a readily accessible online location (Salesforce)

• Call quality monitoring used to improve effectiveness while maintaining efficiency

Ease of Reaching Office Staff by Phone: One year later (July 2015, 27th percentile)… what are we missing?

Efficiency vs. Effectiveness:The Need for Call Quality Monitoring

Call Quality Monitoring

• Service level improvements were necessary but not sufficient.

• What’s the recipe for a high-quality call?

– Opinions varied within and between call centers

– Teams worked together to create and apply “enterprise” standards

• Call quality monitoring:

– Within teams produced some benefits

– Across teams (calibration) is producing more benefits

Ease of Reaching Office Staff by Phone: One year later (May 2016, 52nd percentile)…


“LOAD LEVELING” AND SCHEDULING TEMPLATE OPTIMIZATION

Load Leveling Reason for Action

• Ambitious new patient volume goals

• Many stakeholders concluding that we’re “out of space”

– clinic

– infusion

– OR

• Are long lines and wait times?

– a capacity problem

– a capacity management problem

– all of the above

Start with a 5-day clinic week, 2 X 4-hour blocks per day

Add total number of exam rooms and throughput expectation range per room

Minimum Efficiency: [22*(5.6/2)] = 61.6 patients per ½ clinic day

Maximum Efficiency: [22*(8.8/2)] = 96.8 patients per ½ clinic day

Add 6-month historical visit volume for all providers who practice in this clinic location

• Conclusion:

– Space is available, but volume is unevenly distributed

– We need to redistribute volume from Tuesday and Wednesday mornings

Add or subtract visits from each ½ day volume distribution to “level” within the benchmark range

• If we redistribute volume, we have space for an additional 90 visits per week (4,680 per year)

– Average efficiency of ~7 pts per exam-room*day

Load Leveling: Transition from Concept to Practice

Define group

• Meet with team leaders• Review and confirm team assignments

Interview

• Meet with each provider• Document space needs and other requirements

Compile

• Compile results and review with team leaders• Resolve conflicts and clarify priorities as necessary* (difficult decisions here)• Create current and future state schedules

Create• Develop new scheduling templates and implement transition plan

Potential impact of extended clinic hours:7 am vs. 8 am clinic start time

• Each additional hour in a 22-room clinic accommodates 77-121 additional visits per week

Hour-level detail to identify additional load leveling options

• Women’s Center Visit Volume by Hour of Day and Day of Week

– Overloaded on Wednesdays at 0900 and 1000

– Additional capacity everyday

• 0700-0800

• noon

• 1500-1700

– Plenty of additional capacity on Fridays

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Before and After Results Wednesday Mornings8 am – 12 pm

Thursdays

MondayMornings (8 am)

Before and After Results

• Increasing volume over time*:

– 10% increase in all visits

– 15% increase for New Patients & Consults

•

*Other contributing factors include: new / more MDs, marketing, improved information delivery, Hawthorne effect


WOMEN’S CENTER: CLINIC OPERATIONS AND LEADER STANDARD WORK

Clinic Operations Reason for Action

• Ambitious goals set for Patient Access and Experience

– Improve patient experience in the outpatient setting

• Develop mechanisms for full coordination of care

• Develop stable team of care providers, organized around disease sites

• Improve efficiency of care

• Improve access to care

– Create a better working environment for teams

• Optimize our care model

• Working to “top of license” / increase sense of professional satisfaction

• Allow ongoing involvement of MD’s, physician extenders, RN’s, team members in clinic operations


Clinic Operations Reason for Action

• Step 1: Co-location and level-loading of providers

• Step 2: Continuous improvement = need for management structure

– Place and process to:

• Document, follow and improve standards

• Share information

• Share performance

• Improve performance

• Share / replicate the efforts (model cell)

Lean Management System

• Performance Boards

• Problem Solving Huddles with Frontline Staff

• Leadership Rounding

• Continuously improve standard work

Performance Management Centers and Framework

Performance

Problems

Responses

PDSA / A3

Everything is linked to strategic objectives “True North”

Long and short term trends for metrics of interest

Daily tracking where applicable

Top contributors

Countermeasures and responses

Performance Management Framework

Benefits of Standard Work?

• Provides baseline for improvement activities

• Difficult to make lean implementations "stick" without standardized work

• Improving standardized work is an on-going process

• Adds discipline to our culture

STD WORK

Perfo

rmance

Time

STD WORK

Perfo

rmance

Time

Process Improvement


Leader Doers

Performance

Problems

Responses

Standard Work

Training to Standard

Work

Adherence to Standard

Work


1. Do you have Standard Work?

Leader Doers

Performance

Problems

Responses

Standard Work


Work


Work


2. Does everyone know the Standard

Work?

Leader Doers

Performance

Problems

Responses

Standard Work


Work


Work


3. Is everyone doing the Standard

Work?

Performance Management Culture in Ambulatory

Service Line Leadership

Performance Improvement

Forums

PurposeWhat

Decide on the

project(s)

Drive the project(s)

Managing for daily

improvement (MDI)

Lin

e o

f S

ight

Service Line

Meetings

Ad-hoc PI Work/

Meetings

Standard Work

Daily Huddles

Frontline staff


•Leader Standard Work

•Performance Board

•Metrics

•Document all Performance Improvement Efforts (Countermeasures)

•Standard Work for huddles, meetings

Limited Execution in Performance Management

Service Line Leadership

Performance Improvement

Forums

PurposeWhat

Decide on the

project(s)

Drive the project(s)

Managing for daily

improvement (MDI)

Lin

e o

f S

ight

Service Line

Meetings

Ad-hoc PI Work/

Meetings

Standard Work

Daily Huddles

Frontline staff


•Leader Standard Work

•Performance Board

•Metrics

•Document all Performance Improvement Efforts (Countermeasures)

•Standard Work for huddles, meetings


• Without

– Performance Management Framework

– Performance Improvement Forums

= Engaged but frustrated physicians

= Little follow through and accountability on projects

= Lack of understanding of what else is happening

Decide on the

project(s)Service Line Leadership


• Without

– Performance Management Framework

– Performance Improvement Forums

= Previously disparate team members coming together

= Lacking accountability to standard work; no feedback loop

= Inconsistent huddles, unknown outcomes

= JDIs on post-it notes

= Is anything having an impact on performance metrics?

Standard Work

Daily Huddles

Frontline Staff

Staff huddles

Ambulatory Performance Board

Leader rounding

Problem Solving

Visual Management

Leader Standard Work

FOLLOW STANDARDS

Staff Standard

Work

Auditing of Standard

Work(Kamishibai)

Leader Standard

Work

•Clearer

expectations

•Share

challenges

with staff

Ambulatory Performance BoardPerformance

(Outcome Measure, Trend over time)

Problems (Process

Measure, Stratification)

IMPROVE STANDARDS

•Engage staff in

performance

metrics

Ambulatory Performance Board

SOLVE PROBLEMS

MDI MDI Tracker

Project Tracker

•Track progress

•Assign

accountability:

who and when

•Staff excited to

see changes

being made

Performance Improvement Meetings/Reviews

• Purpose and Standard Work for all meetings:

– Huddles; PI Meetings, Leader Rounds, Service Line Leadership Meetings

• Includes pre- and post-meeting responsibilities; role clarity

Daily Huddle Standard Work

- Pre-Huddle-Huddle

-Post-Huddle

• Tracking progress on key elements

• Spread should happen faster

– Come and see

– Core leaders and reinforcing sponsors are similar

Model Deployment - Spread

Workplan Assignment Breast

/ Plast

ics

GYNGU GI Head/N

eck

Thoracic

/Lung

Hemato

logy

Pediatri

csAmbulatory Operations Structure

Deployment Scorecard

Service Line

Structure

(Vanilla)

ROLES

Defined Service Line Roles

Identify Service Line leads

Sign-off from Service Line leads

MEETINGS SL Leadership Meeting Structure Defined

SLAs SL Service Level Agreements (SLAs) with Ancillary Groups

METRICS Establish SL Metrics

PROJECT LIST Develop List of Ongoing Projects and Status

Establish Workgroup Meetings

Establish Daily Operations Huddle Structure

ROUNDS Establish Leadership Rounding Process & Tools

PERF BOARD Deploy Performance Board Process & Tools

Develop go live support plan for SL & PI

Identify team members

Quickly gather lessons learned

Tweak model leveraging lessons learned

Support Team

Service Line

Structure

(Vanilla)

ROLES

Performance

Improvement

Management

MEETINGS

Problems Solved: Daily Huddles

• Daily (morning and afternoon) huddle issue identification and resolution examples:

– Financial issues (one-time-only, HMO)

– Patient recently discharged with pain

– Wait times and drilled down on issues

– Tomorrow’s preparation (volume, staffing)

– Two VIPs were immediately planned for, identified, and taken in without a wait

– Missing orders were entered prior to start of clinic (after morning huddle)

Problems Solved: Just Do Its

• Standard Work Improvements:

– Scheduler prints medication list for patient to review

– Nurse walks patient out and ensures all steps of medication review and reconciliation are completed prior to check out

– Improved hand-off of patient from one visit to the next (Imaging to MD)

Work in Progress

• Larger Projects Underway:

– RN Visit only template, work flow

– Nurse Practitioner Survivorship clinic

– Duplicate visits reduction (Oncologist & Surgeon)

– Continued level loading opportunities

– Physician access

– Off template booking reduction

Results: In Clinic Wait Time

• Improvements in Standard Work

New Clinic Opens

Not following standard work for

data collection process

Changed standard work for patient flow

/ hand-offs

Continuous monitoring, auditing, and improvement of

standard work

Pt Arrival to In Exam

Room

Adjusted = Scheduled

Appt Time to In Exam

Room

Resistance to Implement

• “Too many meetings”

– Now covering more ground

– Purpose, standard work, and visual management reduces redundant efforts of well-intentioned staff

• “Another place to document”

– Only place to tell the story to staff and to leadership

• “This is executive leader X’s idea”

– Culture change was organic

Staff Insights

• “The huddles are beneficial, it’s a time to think with our coworkers about

what is working, what isn’t working, and what we can do better”

• “I like to see the connection between what we do and how that translates

into data”

• “ I often see the patients and families looking at the board; at first, I was

concerned, now I see they like to know we are focused on their experience”

• “I’ve learned more about the business of ambulatory – that we can measure

wait times in the waiting room and how many days it takes to get an

appointment is really neat! It makes we realize I play a role in improving the

data.”

• “Getting together at the end of every day to debrief has helped us address

issues immediately – it feels good to have a voice and effect change”


AMBULATORY CLINIC REDESIGN: CALL TO ACTION REVISITED

Initial Observation (Q2 2014):New patient visits are not converting to ‘treatments’

Integrated Access

Team (IAT)

• Launched on 7/31/14 to identify and

minimize conversion barriers in the patient access pipeline

IAT: One year laterIncreased patient / visit conversion in all categories

*Other contributing factors include: new / more MDs, marketing, patient experience and culture of service initiatives, improved

information delivery, Hawthorne effect

One year later

• Increased new patient and visit conversion in all categories*

IAT: One year laterPatient experience scores have improved in several key categories

Results shown are National Percentile Rank; Outpatient; Duarte only; by Date of Service

One year later

• National

rank has increased by 9-20 percentage points in

several outpatient satisfaction categories*

+55% +35% +50% +59%

IAT: Second year of effortsPatient experience scores are flat: Process improvements are

essential but not sufficient

Results shown are National Percentile Rank; Outpatient; Duarte only; by Date of Service

Outpatient Scheduling

Outpatient Registration


LESSONS LEARNED &CLOSING

CBI Framework: Mindset > Skillset > ToolsetInterdependent Components, and Sequence Matters…

Mindset Skillset Toolset

The culture of your

organization is:

• Evidence based

• Data driven

• Process oriented

• Transparent

• Collaborative

Your staff is

proficient in:

• Applying scientific thinking to their work

• Using Visual Management

Tools and

Technology:

• Have been deployed based on organizational needs, rather than what vendors can offer


Lessons Learned

• Lean & BI alignment prepares the organization to do something with data

• Visual display of information drives call to action

– Call Center, Capacity Management were long-standing anecdotes and debate

• Mindset is the key to sustainment, and takes time

• Evolution is daily, and ongoing

– Happening as we speak

Questions?

Thank You!

• Kim Carli

– [email protected]

• Doug Stahl

– [email protected]

results focused process driven ambulatory clinic …...results focused process driven ambulatory...

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