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 ProjectIntegrating Effective Disease Management Into Primary Care Using Lean Six-Sigma ToolsJohn Oujiri, MDCynthia Ferrara, MSSt. Mary’s/Duluth Clinic Health System
2 St. Mary’s/Duluth Clinic Health System (SMDC) Integrated health systemMain Campus in Duluth,MN with three neighborhood sites16 regional clinics throughout northeast MN and northwest WI400+ 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 people18.7 people per square mile11.4% 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-goingSustain and Continuous Improvement7. Staged Implementation Pilot Sites 1-3 Feb 08-July 086. Report to Sponsors November 20075. Midway Report and Feedback August 2007Sponsor Update Frequent3. Weekly Action Meetings Start: June 20072. 4-Day Breakthrough Work-out June 2007Pre-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 perspectiveForms the basis for an implementation planDemonstrates waste, gaps and major constraints in care deliveryIdentifies value-added steps needed
8 Major Red Flags Identified Lack of consistency across clinics in keysub-processes, roles and workflowsUnder-utilization of EPIC (Electronic Health Record) capabilities and a variety of individual physician solutions rather than a system solutionDaily mountains of rework by the most constrained resources in Primary CareInformation 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 planningSignificant Patient Activation opportunityJohn 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 scopeof licensure & abilitiesAutomate work “That No Human Should Do”John OGuiding principles during the processMove as much work forward and out the exam room as possibleDesign Centralization into ourprocess wherever it makes senseCreate 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 EPICStandardization Work gets done so that the outcomes are more predictableMistake Proofing Building error prevention into the design of the processConstraints 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 EPICJohn O
13 Elements of the New Design: Pre-Visit Planning Centralized, pre-visit planning takes place for every scheduled visitStandard process, questions and protocolsLabs ordered per protocolHealth Maintenance alertsInitial Med Review takes place before patient appointmentAndreaThe 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 roomallows 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 roomingA standardized rooming process (i.e. socks/shoes off for diabetic visits, BP measurement, depression screening)Med Review by CA at roomingLoad and pend Best Practice Alerts for physician order approvalSharon MRooming is standardizedMed review for changes since reconciliation
15 Elements of the New Design: Physician/Credentialed Practitioner Information needed for the encounter has already been prepped for providerProvider will:Reconcile med listUpdate Problem ListMake a follow-up appt plan with each visitEnter future ordersSupport patient’s behavior change effortsEnter patient instructionsPeggyThere arell work is done and available for the providerRN 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 assessmentRN Coaching ModelDisease coaching and care coordination is a value-added service that payers have been willing to reimburseMotivational Interviewing skillsUse of enhanced take-home patient instructionsCreation of a Disease Management Care PlanEPIC / MyHealth online tools allow patients to access their medical record, review labs, etcSharon Q
17 Elements of the New Design: Check-Out 100% of patients are directed to check outEvery patient receives an After Visit SummaryCommunicates what occurred during the visit Includes instructions and updated Med ListNext appointment scheduledFuture labs ordered, per provider and protocolLisa
18 Process Steps and Perceived Complexity These additional up front process tasks represent “Prevention” of process rework and delays on the day of encounterAppears 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 MeasuresProcess% 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
20 Financial: Physician and Staff Productivity ClinicalOptimal Diabetes Management: 25%Customer ServiceAchieve 10% increase in overall patient satisfactionFinancial: Physician and Staff ProductivityRVU’s/Provider FTEDirect Operating MarginEncounters 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 clinicsIncorporates evidence-based guidelines in assessing quality performanceProcess and outcome measurement, evaluation and managementData 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=556Implementation 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.
23 DC-Clinic C Diabetes Management June 2007 – June 2008 n=981 Feedback to Physicians and Staff: Physician LevelDC-Clinic C Diabetes Management June 2007 – June 2008 n=981
25 Phoenix Project: Impact on Disease Management Integration of population-based disease management into “routine” careDecrease 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 possibleImproved patient engagement in self-managementRN Coach: Alert fires within EHR for patients meeting criteria for referralPatients receive After Visit Summary that clearly communicates what occurred during their visit, including instructions and “next steps”Prepared proactive care teamLab results available at time of appt increase effectiveness of pt visitIntentional 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, 1513Physician EngagementClinical InertiaUnexplained VarianceReluctance 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 resourcesValue must be defined by external customer (patients and families) rather than internal (staff, physician, payers)
27 Lessons LearnedImplementing lean thinking in a traditional health care culture is not “for the faint of heart” (IHI)Communication is essentialDo not underestimate the response to change in status quoThe vocal, unhappy minority cannot steer the shipSenior leadership support is invaluableInvolve patients in planning processNot a “quick fix”Improvement to metrics will take timeWill require sustained commitmentClear definition of roles and responsibilities will help project move forward“You get what you expect and you deserve what you tolerate”Mark B
29 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: ,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 onNorman, Gary, Kaczmarski, Phil, and Pexton, Carolyn. (2003, November 26). Integrating Six Sigma with Lean & Work-Out in Healthcare.iSixSigma.com.Pexton, Carolyn. (2003, May 13). Framing the Need to Improve Health Care Using Six Sigma Methodologies. iSixSigma.com.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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