The Phoenix Project

Integrating Effective Disease Management Into Primary Care Using

Lean Six-Sigma Tools

John Oujiri, MDCynthia Ferrara, MSSt. Mary’s/Duluth Clinic Health System

•Integrated health system

•Main Campus in Duluth,MN with three neighborhood sites

•16 regional clinics throughout northeast MN and northwest WI

•400+ physicians

St. Mary’s/Duluth Clinic Health System (SMDC)

•SMDC clinics are located over 25,000 square

miles and serve a population of nearly half a

million people

•18.7 people per square mile

•11.4% of population below

poverty level (2004)

Develop a standard set of workflows for delivering evidence-based care that provides a consistent clinical experience for patients and a consistent

process for care teams.

Differentiate our organization to payers, employer groups, and government agencies.

Goal of Phoenix Project

Phoenix Lean Process Road Map

8. Control Phase On-goingSustain and Continuous Improvement

7. Staged Implementation Pilot Sites 1-3 Feb 08-July 08

6. Report to Sponsors November 2007 5. Midway Report and Feedback August

2007

4. Sponsor Update Frequent

3. Weekly Action Meetings Start: June 2007

2. 4-Day Breakthrough Work-out June 2007

1. Pre-Launch Planning May 2007

Cross-functional teams from pilot sites (3) assembled to apply lean design concepts to

core processes and systems in four-day event.

Empowered to develop solutions/actions.

Core Breakthrough Team Members: Staff and physicians from pilot sites and key

leadership.

4-Day Breakthrough Work-Out

Breakthrough Design Map

© 2004 Leap Technologies, Inc.

I n Between Visit Activities and Pre Visit Planning Sub Process

Big Ideas and Enabling Tools:

PROACTIVE

Schedules interaction via:-Call-My Chart-Kiosk @ mall- Clinic Kiosk- Home

Telehealth monitors- B/P- CHF-Blood Sugars

•Automated Triggers•Automatically order of needed test as future and & drive work effort (prioritize)•Risk Stratification•Role change of human to technology

Intervention is:-Patient Specific-Measurable-Adjusted as needed

-Must be documented via email, letter or ?

Previsit Planning- prior to day of, automatic scrubber determines needed tests and orders them

Major Process Steps

Assumptions & Open Questions

Assumption: Base of patients already ID’d

Philosophy:Human Touch vs. Automated

Outside Labs? Appointment

happensCheck out should inititiate the “in between” process

Combining Med vs. problem list scrubbing

Coordinate visit with all needed services

Safety Net?

Care Coordinator

Health Alerts

Developed in Workshop by:•Chris• Mike• Lisa• Dennis• Krister• Karen

Identified Patient Registry

Automated reporting & Analysis Tools “Clarity on Steroids” business intelligence tools

Patient Education:•Webcasts• Podcasts• Link to Comm. Resources• Email• My Chart

PatientCenter, Not Disease Patient

REACTIVE

What aboutProvider Autonomy?

Out of Care PT

Patient Kiosk:• In Clinic• In retail locations• Other public sites

Integration System:Example: vaccination program

Staff Education and Development:- Scripting

Need to define Community Resources!

Policy/Leadership Decisions:

Key: Standardize protocols and use them as much as possible

Create a Problem List and Med List Update Policy

Create a policy on Outside Labs which supports CCSI

? Hospital or Assisted Living, Nursing Home Pts?

Value Stream Mapping

Demonstrates waste, gaps and major

constraints in care delivery

Identifies value-added steps needed

Captures the current reality

Defines value from customer perspective

Forms the basis for an implementation plan

Major Red Flags Identified

• Lack of consistency across clinics in key sub-processes, roles and workflows

• Under-utilization of EPIC (Electronic Health Record) capabilities and a variety of individual physician solutions rather than a system solution

• Daily mountains of rework by the most constrained resources in Primary Care

• Information Gaps at several critical points in the delivery of Primary Care. Waste identified during encounter and rooming process due to lack of any pre-visit planning

• Significant Patient Activation opportunity

Four guiding principles developed to help move from the current

process to an effective and efficient model of care delivery.

“Do the right thing. Do it right”

Phoenix Guiding Principles

Practice to the full scope

of licensure & abilities

Automate work “That No Human Should Do”

Create and implement a Common Way of Doing Things across the

Duluth Clinic system

Design Centralization into ourprocess wherever it makes sense

Lean Strategies Applied

• Visual Management Use of simple signals and signs in EPIC

• StandardizationWork gets done so that the outcomes are

more predictable• Mistake Proofing

Building error prevention into the design of the process

• Constraints Analysis / Bottleneck Reduction Improving flow by designing to overcome resource constraints. Move work “forward”

• Automation Taking routine tracking tasks out of the hands

of people and into EPIC

Phoenix Primary Care Model Components

Productive Interactions Informed, Activated Patient Prepared, Proactive Practice Team

Pre-Visit Planning Schedule Appointment Review Med List Labs First Scheduled/Ordered Health Maintenance Alerts Between Visit Planning Visit Prep Questions Out-of-range/Out-of-Contact Pts Info from Outside Providers

Day of Visit: Rooming Vitals/Rooming Form

RN Coaching Med List (Clarify) BPA based on criteria Load & Pend Refills Initially Diabetic Only Pend BPA’s

Day of Visit: Clinician Check Out Views all data Prints AVS/Med List Reconciliation of Med List

Other RN DM Programs Future Appts Patient Instructions/follow-up Warfarin; Diamond; Hypertension Referrals Dx and Orders

PATIENT

Elements of the New Design:Pre-Visit Planning

• Centralized, pre-visit planning takes place for every scheduled visit– Standard process, questions and protocols – Labs ordered per protocol– Health Maintenance alerts

• Initial Med Review takes place before patient appointment

• “Lab First” tasks are completed prior to rooming• A standardized rooming process

(i.e. socks/shoes off for diabetic visits, BP measurement, depression screening)

• Med Review by CA at rooming• Load and pend Best Practice Alerts for

physician order approval

Elements of the New Design:Check-in and Rooming

• Information needed for the encounter has already been prepped for provider

• Provider will:– Reconcile med list– Update Problem List– Make a follow-up appt plan with each visit– Enter future orders– Support patient’s behavior change efforts– Enter patient instructions

Elements of the New Design:Physician/Credentialed Practitioner

• Health risk, knowledge and activation assessment• RN Coaching Model

– Disease coaching and care coordination is a value-added service that payers have been willing to reimburse

– Motivational Interviewing skills

• Use of enhanced take-home patient instructions• Creation of a Disease Management Care Plan• EPIC / MyHealth online tools allow patients to

access their medical record, review labs, etc

Elements of the New Design:Patient Activation

• 100% of patients are directed to check out• Every patient receives an After Visit Summary

– Communicates what occurred during the visit Includes instructions and updated Med List

• Next appointment scheduled• Future labs ordered, per provider and protocol

Elements of the New Design:Check-Out

12

34

5

Old

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2

4

6

8

10

12

14

16

Old

New

Appears to be “more”

complexity in the front end of

process

These additional up front process tasks

represent “Prevention” of

process rework and delays on the day of

encounter

Process Steps and Perceived Complexity

Process

% of patients with:Completed pre-visit planningHealth Maintenance alerts satisfiedLab orders completeMedication list reviewedRN coaching appointment (per selection criteria)After Visit Summary, Med list and next appt scheduled

Control PhaseKey Performance Metrics

*Balanced Scorecard/Strategy Map Measures

Clinical* Optimal Diabetes Management: 25%

Customer Service

* Achieve 10% increase in overall patient satisfaction

Financial: Physician and Staff Productivity

* RVU’s/Provider FTE* Direct Operating Margin* Encounters per Support Staff FTE

Feedback to Care Teams

Routine reporting feedback loop

• Data is provided at physician,clinic and system level for all SMDC clinics

• Incorporates evidence-based guidelines in assessing quality performance

• Process and outcome measurement, evaluation and management

• Data is transparent within the health system

Diabetes Optimal Management% of Patients Meeting All 7 Measures**

Phoenix Project Pilot Site 1June 07-July 08

n=556

14.6

16.5

15.9

14.8

16.8

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June 07 Sept 07 Dec 07 Mar 08 June 08 July 08

Date

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Implementation Feb 08

(*) Includes: A1C in last 6 months Blood Pressure <130/80A1C <7% Tobacco FreeLDL in last 12 months Anti-platelet use in patients over 40 y/oLDL <100 mg/dL.

DC-Clinic CDiabetes ManagementJune 2007 – June 2008

n=981

% of Patients with Diabetes with Blood Pressure <130/ 80

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Jun-07 Sep-07 Dec-07 Mar-08 Apr-08 May-08 Jun-08

Target = 50%

Feedback to Physicians and Staff: Physician Level

Encounters Per Support Staff FTEPhoenix Pilot Site #1

156149 149

174

190

143

172 171

152 151 153 149

205214

-

50

100

150

200

250

FY 2005 FY 2006 FY 2007 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008

July August September October November December January February March April May

Fiscal Period

En

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Encounter Per Direct Support Staff FTE Poly. (Encounter Per Direct Support Staff FTE)

Implementation Feb 08

Phoenix Project:Impact on Disease Management

• Integration of population-based disease management into “routine” care

• Decrease in missed opportunities for lab work and increased % of patients up-to-date (A1C, LDL, etc)

• Future appointments and labs scheduled before patient leaves the clinic, whenever possible

• Improved patient engagement in self-management– RN Coach: Alert fires within EHR for patients meeting criteria for referral – Patients receive After Visit Summary that clearly communicates what

occurred during their visit, including instructions and “next steps”

• Prepared proactive care team– Lab results available at time of appt increase effectiveness of pt visit

• Intentional and focused efforts to enhance disease management has led to health plan collaboration and improved reimbursement structure

Ongoing Challenges

• Change Management– “There is nothing more difficult to carry out, nor more doubtful of

success, nor more dangerous to handle, than to initiate a new order of things.” Machiavelli, The Prince, 1513

• Physician Engagement

• Clinical Inertia

• Unexplained Variance• Reluctance in system to hold individuals accountable for

implementation and results, i.e. “culture of consequences”

• “No Net New“– Ensuring that efficiencies gained allow for value added activities

without increase in resources

• Value must be defined by external customer (patients and families) rather than internal (staff, physician, payers)

Lessons Learned

• Implementing lean thinking in a traditional health care culture is not “for the faint of heart” (IHI)

• Communication is essential• Do not underestimate the response to change in status quo• The vocal, unhappy minority cannot steer the ship• Senior leadership support is invaluable• Involve patients in planning process• Not a “quick fix”

– Improvement to metrics will take time– Will require sustained commitment

• Clear definition of roles and responsibilities will help project move forward

• “You get what you expect and you deserve what you tolerate”

Questions ?

BibliographyAverbeck B. Bringing evidence-based best practices into practice. Health Management Technology November 2005.

Averbeck, Beth and Beth Waterman. (2007, May 17). Embedding Reliability in Ambulatory Care: The Care Model Process. Presented at the 2007 ICSI/IHI Colloquium at Minneapolis, Minnesota.

Bodenheimer T., et al.: Improving primary care for patients with chronic illness. JAMA 288:1775-1779,October 9, 2002.

Bodenheimer T., et al.: Improving primary care for patients with chronic illness. Part Two: The chronic care model. JAMA 288:1909-1914,October 16, 2002.

Dorr D., et al.: Disease management: Implementing a multi-disease chronic care model in primary care using people and technology. Disease Management 9:1-15, February 1, 2006.

Going Lean in Health Care. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2005. (Available on www.IHI.org)

Norman, Gary, Kaczmarski, Phil, and Pexton, Carolyn. (2003, November 26). Integrating Six Sigma with Lean & Work-Out in Healthcare.iSixSigma.com. http://healthcare.isixsigma.com/library/content/c031126a.asp

Pexton, Carolyn. (2003, May 13). Framing the Need to Improve Health Care Using Six Sigma Methodologies. iSixSigma.com. http://healthcare.isixsigma.com/library/content/c030513a.asp

Selna, March. (2006, May 11). EHR-based Disease Management, Success & Challenges at Geisinger Health System. Presented at the 2006 Disease Management Colloquium at Philadelphia, Pennsylvania.

Solberg L.,et al.: Challenges of Change: A qualitative study of chronic care model implementation. Annals of Family Medicine 4: 317-326, July-August 2006.

Wagner E,et al .: Improving chronic illness care: Translating evidence into action. Health Affairs 20;64-78, November/December 2001.