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The Phoenix Project Integrating Effective Disease Management Into Primary Care Using Lean Six-Sigma Tools John Oujiri, MD Cynthia Ferrara, MS St. Mary’s/Duluth.

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Presentation on theme: "The Phoenix Project Integrating Effective Disease Management Into Primary Care Using Lean Six-Sigma Tools John Oujiri, MD Cynthia Ferrara, MS St. Mary’s/Duluth."— Presentation transcript:

1 The Phoenix Project Integrating Effective Disease Management Into Primary Care Using Lean Six-Sigma Tools John Oujiri, MD Cynthia Ferrara, MS St. Mary’s/Duluth Clinic Health System

2 St. Mary’s/Duluth Clinic Health System (SMDC)
Integrated health system Main Campus in Duluth,MN with three neighborhood sites 16 regional clinics throughout northeast MN and northwest WI 400+ physicians

3 11.4% of population below poverty level (2004)
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)

4 Goal of Phoenix Project
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.

5 Phoenix Lean Process Road Map
8. Control Phase On-going Sustain 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 Sponsor Update Frequent 3. Weekly Action Meetings Start: June 2007 2. 4-Day Breakthrough Work-out June 2007 Pre-Launch Planning May 2007

6 4-Day Breakthrough Work-Out
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.

7 Value Stream Mapping Captures the current reality
Defines value from customer perspective Forms the basis for an implementation plan Demonstrates waste, gaps and major constraints in care delivery Identifies value-added steps needed

8 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 John O.

9 “Do the right thing. Do it right”
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”

10 Phoenix Guiding Principles
Practice to the full scope of licensure & abilities Automate work “That No Human Should Do” John O Guiding principles during the process Move as much work forward and out the exam room as possible Design Centralization into our process wherever it makes sense Create and implement a Common Way of Doing Things across the Duluth Clinic system

11 Lean Strategies Applied
Visual Management Use of simple signals and signs in EPIC Standardization Work 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 John O


13 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 Andrea The Pre-Visit encounter will include reviewing and updating the medication list and documenting allergies which were previously part of the rooming process. Move work forward and out of the exam room allows time to evaluate and schedule needed activities and education

14 Elements of the New Design: Check-in and Rooming
“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 Sharon M Rooming is standardized Med review for changes since reconciliation

15 Elements of the New Design: Physician/Credentialed Practitioner
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 Peggy There are ll work is done and available for the provider RN is involved by appointment or referral for routine and as needed patient education

16 Elements of the New Design: Patient Activation
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 Sharon Q

17 Elements of the New Design: Check-Out
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 Lisa

18 Process Steps and Perceived Complexity
These additional up front process tasks represent “Prevention” of process rework and delays on the day of encounter Appears to be “more” complexity in the front end of process

19 Control Phase Key Performance Metrics
Control Phase Key Performance Metrics *Balanced Scorecard/Strategy Map Measures Process % of patients with: Completed pre-visit planning Health Maintenance alerts satisfied Lab orders complete Medication list reviewed RN coaching appointment (per selection criteria) After Visit Summary, Med list and next appt scheduled

20 Financial: Physician and Staff Productivity
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

21 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

22 Diabetes Optimal Management % of Patients Meeting All 7 Measures
Diabetes Optimal Management % of Patients Meeting All 7 Measures** Phoenix Project Pilot Site 1 June 07-July 08 n=556 Implementation Feb 08 (*) Includes: A1C in last 6 months Blood Pressure <130/80 A1C <7% Tobacco Free LDL in last 12 months Anti-platelet use in patients over 40 y/o LDL <100 mg/dL.

23 DC-Clinic C Diabetes Management June 2007 – June 2008 n=981
Feedback to Physicians and Staff: Physician Level DC-Clinic C Diabetes Management June 2007 – June 2008 n=981

24 Implementation Feb 08

25 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

26 Ongoing Challenges Change Management Physician Engagement
“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)

27 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” Mark B

28 Questions ?

29 Bibliography Averbeck 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: ,October 9, 2002. Bodenheimer T., et al.: Improving primary care for patients with chronic illness. Part Two: The chronic care model. JAMA 288: ,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; (Available on Norman, Gary, Kaczmarski, Phil, and Pexton, Carolyn. (2003, November 26). Integrating Six Sigma with Lean & Work-Out in Pexton, Carolyn. (2003, May 13). Framing the Need to Improve Health Care Using Six Sigma Methodologies. 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: , July-August 2006. Wagner E,et al .: Improving chronic illness care: Translating evidence into action. Health Affairs 20;64-78, November/December 2001.

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