1. Business Process Reengineering in Health Care IT
Types of BPR
Project Management Implications
Examples from the Field
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Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

2. Introduction of Members
Lee Farabaugh
Susan John
Larry Katzovitz
Eric Lott
Ashwini Patki
Jessica Pearce
Josh Snow
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Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

3. Group 4: Project Agenda
Overview of Business Process Redesign models used in healthcare.
Applicability of principles of Business Process redesign related to overall Project Management methodologies.
Effectiveness of such models as part of a Healthcare IT initiative.
Examples where organizations have used such a model as part of a Healthcare IT initiative.
Class exercise and questions.

4. Business Process Redesign(BPR) in Healthcare
What?
Why?
How?
Methods
Relation to project management

5. HELPS AN ORGANIZATION STAY COMPETITIVE
BPR – What & Why?
BPR is a set of activities undertaken to make sustained improvements in the …
SPEED(lead time)
QUALITY
COST OF PROCESS
HELPS AN ORGANIZATION STAY COMPETITIVE
IN THE MARKETPLACE

6. BPR – How? NEW PRODUCT REDESIGN HIGH LEVEL ASSESSMENT RESULTS IN
(FOR EFFICIENCY & ALIGNEMENT OF MUTUAL GOALS)
BUSINESSS MISSION
GOALS
CUSTOMER NEEDS
STRUCTURED ORDERING OF WORKSTEPS
MEASURED
IMPROVED
(OR) ELIMINATED

7. BPR - Methods LEAN SIX SIGMA TOTAL QUALITY MANAGEMENT (TQM) KAIZEN
PLAN, DO, STUDY ACT (PDSA)
CLINICAL MICROSYSTEM MODEL
TALENT PROFILING

8. Health Care Challenges that encourage BPR Expectations from BPR models Highlighted solutions Applications of BPR models BPR Obstacles

9. Expectations from BPR models
Increase in efficiency
Reduce medical and medication errors
Health care cost reduction
Better access and quality in healthcare
Procedure optimization
Time effectiveness
Customer and health care provider satisfaction

10. Highlighted solutions
Automating and monitoring processes in healthcare
Redesigning or improving clinical processes where necessary and possible
Identifying patient expectations and improving patient care processes for better customer services.
BPR models: The business process redesign (BPR) models are the processes that target improvisation and optimization of process outputs while maintaining quality.

11. LEAN
What?
How?
What helps ?
Conclusion

12. LEAN – What? RETHINKING & REDESIGN OF BUSINESS PROCESS
SHORTENED LEAD TIMES
EFFICIENCY IMPROVEMENTS
PROCESS COST REDUCTION
REVENUE INCREASE
REDUCED PROCESS WASTES
IMPROVED CUSTOMER SATISFACTION

13. LEAN – How?
HIGH LEVEL ASSESSMENT
WHO ?
PRODUCT DELIVERED ?

14. Improving Processes by eliminating…
LEAN – How?
Improving Processes by eliminating…
STEPS THAT HAVE NO VALUE
PROCESS WASTE
WAITING TIME

15. LEAN – How? (Six steps) Value – Who is the customer?
Value Stream – What is the service or product being provided to the customer?
Flow – Did the team identify the non-value added distances traveled by parts?
Pull – Waste elimination steps identified at every step of the process, to produce more than before in a way that is value added at the time of delivery.
Perfection - Optimize your process for what you are trying to achieve.
Replication – Can this process improvement be replicated in other parts of the business.
6 steps to think Lean.
1.Value- Ex: Who is the customer?
2. Value Stream – Ex:What is the service or product being provided to customer?
3. Flow- Ex: Did the team identify the non- value added distances traveled by parts.
4. Pull- Ex: Waste elimination steps identified at every step of the process, to produce more than before in a way that is valued added at time of delivery. Example: Dell Computers.
5. Perfection - Ex: Optimize your process for what your tring to achieve.
6. Replication- Ex: Can this process improvement be replicated in other parts of the business.

16. LEAN – What helps? LEAN IMPLEMENTATIONS
STRONG MANAGEMENT SUPPORT & SPONSORSHIP
COMMUNICATION OF SHARED GOALS
LEAN IMPLEMENTATIONS

17. TO GAIN COMPETITIVE ADVANTGE OVER OTHER COMPANIES
LEAN - Conclusion
Can be applied to any business process or service industry.
Can be used to dramatically reduce lead times
HR recruitment
New product development
Customer development
TO GAIN COMPETITIVE ADVANTGE OVER OTHER COMPANIES

18. Six Sigma (Six sigma was invented by Motorola in the 1980s)
Analytical approach to indentify the inefficiencies and inadequacies in the process and provide a step by step solution based on analysis of real time data.
Process must have < 3.4 defects per million occurrences (Carrigan, 2006)
Statistical calculation that suggests customer needs /satisfaction to meet % or 6-Sigma level. (Caldwell 2006)
Focuses on customer satisfaction, process improvement and cost reduction. (Breyfogle, 2003)
Uses structured methodology and powerful statistical tools that provide a scientific approach to process improvement and patient safety. (
Six sigma was invented by Motorola in the 1980s. Although Lean and Six Sigma are originally business management models, in recent years the potential of these techniques in health care and in software development is been recognized. (Schweikhart et al 2009)

19. Six Sigma Sub methodologies
DMAIC: Define, Measure, Analyze, Improve, and Control; (improve existing processes )
DMADV: Define, Measure, Analyze, Design, Verify; (develop new processes or products at Six Sigma quality levels) (
Implementing 6sigma:
“Black Belt” = organize of Six Sigma project
“Green belt” = implement and monitor the project.
Define and describe the potential critical processes. Determine measures such as accuracy standards, reproducibility of each process, idendify and verify cause effect relationship between variables, implement the improvement design and establish control over new system via policies/ regulations and document to prevent recurring issues. DMADV has last 2 steps different: Design new process and verfy that the solution fits the problem. People in an organization are certified to implement Six Sigma by allotting them “Black Belt” or “Green belt” status. Black belts organize the Six Sigma project and green belts implement and monitor the project.
Sigma is a statistical calculation that suggests customer needs /satisfaction to meet % or 6-Sigma. Majority of the times healthcare processes rarely go beyond 93% or 3 sigma.

20. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
What is TQM?
Total Quality Management (TQM) is a philosophy that says uniform commitment to quality in all areas of an organization promotes an organizational culture that meets consumers' perceptions of quality.
TQM philosophy focuses on teamwork, increasing customer satisfaction, and lowering costs.
Organizations implement TQM by encouraging managers and employees to collaborate across functions/departments, as well as with customers and suppliers, to identify areas for improvement, no matter how small.
To be effective in improving quality,
Teams of workers are trained and empowered to make decisions that help their organization achieve high standards of quality. Organizations shift responsibility for quality control from specialized departments to all employees. Thus, total quality management means a shift from a bureaucratic to a decentralized approach to control.
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Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

21. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
TQM Principles
The concept of TQM rests largely on five principles: 1. Produce quality work the first time. 2. Focus on the customer. 3. Have a strategic approach to improvement. 4. Improve continuously. 5. Encourage mutual respect and teamwork.
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Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

22. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
TQM Process/Benefits
Process begins by listening to customers' wants and needs and then delivering goods and services that fulfill these desires.
An effective TQM program has numerous benefits.
Financial benefits (lower costs, higher returns on sales and investment, and the ability to charge higher rather than competitive prices)
Improved access to global markets
Higher customer retention levels
Less time required to develop new innovations
Reputation as a quality firm
Only a small number of companies use TQM because implementing an effective program involves much time, effort, money, and patience. However, firms with the necessary resources may gain major competitive advantages in their industries by implementing TQM.
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Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

23. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
What is Kaizen?
( Japanese for "improvement")
Philosophy/practices focusing on continuous improvement in manufacturing activities, business activities, and even life in general.
Refers to activities that continually improve all functions of a business,
Manufacturing to management
CEO to assembly line workers
Kaizen aims to eliminate waste .
By improving standardized activities and processes, aims to eliminating waste
Kaizen was first implemented in several Japanese businesses during the country's recovery after World War II and has since spread to businesses throughout the world.
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Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

24. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
Kaizen Cycle
The cycle of kaizen activity can be defined as:
Standardize an operation
Measure the standardized operation (find cycle time and amount of in-process inventory)
Gauge measurements against requirements
Innovate to meet requirements and increase productivity
Standardize the new, improved operations
Continue cycle ad infinitum
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Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

25. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
Kaizen Elements
The five main elements of kaizen
Teamwork
Personal discipline
Improved morale
Quality circles
Suggestions for improvement
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Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

26. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
Kaizen Results
Major results
Elimination of waste (muda) and incorporation of efficiency
The kaizen five - S framework
Seiri - tidiness
Seiton - orderliness
Seiso - cleanliness
Seiketsu - standardized clean-up
Shitsuke - discipline
Standardization
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Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

27. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
Other BPR Methods
PDSA – Plan, Do, Study, Act
Clinical Microsystem Model
Talent Profiling
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Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

28. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
PDSA – Plan, Do, Study, Act
Three Questions
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
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Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

29. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
The PDSA Cycle
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30. PDSA – UW Rheumatology Office Visit Data Collection
Cycle 1 - Standardized Database & Dictation Template
Cycle 2 - Disease Activity Scoring
Cycle 3 – CPT Visit Coding Level
Cycle 4 – Full Implementation
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Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

31. PDSA – UW Rheumatology Office Visit Data Collection
Improvements
More Complete Data
40% Time Savings
More Effective Patient/Physician Visit
Improved Therapeutic Decision Making
Research Study Revenue
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32. Clinical Microsystem Method
Smallest Replicable Unit
Building Blocks to Larger System
5 P’s - Purpose, Patients, Processes, Professionals, and Patterns  
Improvements – Transformation of Workforce and Culture
Hospital Quality = Quality of Microsystem 1 + Quality of Microsystem 2 + Quality of Microsystem 3 and Microsystem (n)
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Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

33. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
Talent Profiling
Worker rather than Process
Right Person – Right Job
Important Characteristics to be Successful
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Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

34. Project Management Methodologies (Traditional)
Waterfall
Spiral
Build and Fix

35. Traditional Methodology Model
Identify Deficiencies
Define Specific Proposals for Improvement
Proposed System is Designed
New System is Developed
System is Implemented
System is Continuously Evaluated and Maintained

36. Traditional Methodologies Characteristics
Looked to improve existing systems or implement new systems
Task oriented
Processed based
Step-by-step approach

37. Business Process Redesign Characteristics
“Clean Slate”
Outcomes oriented
Priority based
Cyclical approach

38. Business Process Redesign Model
Envision New Processes
Initiate Change
Diagnosis Process
Process Redesign
Reconstruction
Process Monitoring

39. Project Management Methodologies (Agile)
Scrum
Six Sigma
Lean

40. Agile Manifesto Individuals and interactions over processes and tools
Working software over comprehensive documentation
Customer collaboration over contract negotiation
Responding to change over following a plan

41. Agile Principles Projects built around self-organized teams
Rapid adaptation to changing circumstances
Continuous attention to technical design
Working product is the measure of progress

42. Business Process Reengineering and Health Care IT
IT often plays a support role in BPR in health care
“What has to happen when you design the new process, you find how information technology is going to be used to support that new process, and if you don’t have that technological capability, you’re going to have to go and get it.” (George W. Whetsell)
CIO has to understand BPR as it applies to his or her specific organization and be innovative in applying that understanding to the IT function within the organization.
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Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

43. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
Denver Health (Lean)
Pure IT project: patient scheduling application development
Project timeline reduced 50%, outside consulting cost reduced 36%.
IS had previously sat “on the sidelines” in lean initiatives, but sought to use lean to make the department more efficient
Challenge was to fit lean concepts to a longer term IT project.
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Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

44. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
Denver Health (Lean)
Rapid Improvement Event (RIE) model was tweaked to fit this specific project
Embedded into project cycle, redefining how project was managed
Custom templates created
Special attention given to lean tools, activity flow, and frequency of RIE events
Involvement of end users
“Red phone” mentality
Used MS Sharepoint to bring stakeholders up to speed with 15 mins of relevant information
Delta team of 3 individuals replaced project governance and took day-to-day responsibility for decision making
25% reduction in internal resource time spent on the project
Training time reduced because trainers were involved from the beginning and became application experts.
Training materials were available before launch, and 80-90% of users were trained ahead of time.
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Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

45. VA’s VistA QUERI system (TQM)
Quality Improvement initiative within the VA, where data from the organization’s nationwide interoperable VistA EMR system is integral to the total process of improving patient outcomes.
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46. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
the structure of the VA and the access to data provided by VistA make it a natural fit for research activities seeking to improve quality, clinical outcomes, and patient satisfaction. As Kizer et al state, “The VHA’s unique portfolio of providing patient care, teaching, conducting research, and continuously measuring outcomes, combined with its large size and national presence, provide for a broad and stable patient base for taking research discoveries and quickly putting them to work, either to improve patient care or to enhance system efficiency. QUERI attempts to purposely link research activities (which generate scientific evidence) to clinical care in as close to real time as possible, thereby leading to rapid adoption of best clinical practices and improvement in patient outcomes.” (Kizer, Demakis, & Feussner, 2000).
Hynes, D. M., Perrin, R. A., Rappaport, S., Stevens, J. M., & Demakis, J. G. Informatics Resources to Support Health Care: Quality Improvement in the Veterans Health Administration. Journal of the American Medical Informatics Association. 2(5),
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47. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
Virginia Mason (Lean)
IT served as a support role to improve areas identified as cost-centers
Implementation of CPOE to reduce unnecessary prescriptions and reduce ER visits due to low refill allowances
Implementation of decision support to alert clinicians when tests fall into the “not useful” category
The problem: high cost for treating migraines and GERD, initially attributed to specialists, but through process scrutiny, late attributed to primary care docs and ED docs.
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48. Bibliography
Alexandrou, Marios (2009). Methodologies. Retrieved from
Beck, K., Beedle M., Bennekum, A., et al. (2001), The Agile Manifesto. Retrieved from
Caldwell, C., Lean-Six Sigma tools for rapid cycle cost reduction, Healthcare Financial Management. Oct 2006, 60 (10)
Corn, J. B., Six Sigma in Health Care, Radiologic Technology. September/October 2009; 81(1): 92-95
Bergman, R. (1994). Reengineering Healthcare. Hospitals & Health Networks. 5 February, 1994,
Breyfogle, F. W., Implementing Six Sigma: Smarter Solutions Using Statistical Methods, 2nd ed. 2003, Wiley, New York, NY.
Carrigan M. D., Kujawa D. Six Sigma in health care management and strategy. Health Care Management. 2006;25(2):
Davenport, D. and Short, J. The New Industrial Engineering: Information Technology and Business Process Redesign. Retrieved from
Guha, S., Kettinger, W., & Teng, T. (1993) “Business Process Reengineering: Building a Comprehensive Methodology”, Information Systems Management, Summer 1993, Vol 10 (3), 13-22
Harrington, T. J., Newman, E. D. (2007). Redesigning the care of rheumatic diseases at the practice and system levels. Clinical and Experimental Rheumatology, 25, S55-S63.

49. Bibliography (cont’d)
Improvement Methods. Institute of Healthcare Management. Retrieved from
Lanham, B., Maxson-Cooper, P. Is Six Sigma the Answer for Nursing to Reduce Medical Errors...: Implementing Six Sigma in Health Care. MedScape Today. Retrieved from
Mahalik, P. Learning to Think Lean: Six Steps with Review Points. Retrieved from
McQueen, H. E. (1993). The healthcare CIO’s role in business process redesign. Computers in Healthcare. February, 1993,
Mohr, J, Batalden, P., Barach, P. (2004). Intergrating patient safety into the clinical microsystem. Qual Saf Health Care, 13,34-38.
Plan-Do-Study-Act (PDSA) Cycle (2008). AHRQ Healthcare Innovations Exchange. Retrieved from
Schweikhart S. A., Dembe A. E. J Investigative Medicine Sep 2
Shaffer, Vi. (2008). Case Study: Denver Health Leverages ‘Lean’ for a Breakthrough in Enterprise Patient Scheduling Implementation. Gartner Industry Research. 17 December, 2008.
Six Sigma. Retrieved from
Six Sigma - What is Six Sigma? Retrieved from