Business Process Reengineering in Health Care IT Types of BPR Project Management Implications Examples from the Field 10/1/20151Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

Introduction of Members Lee Farabaugh Susan John Larry Katzovitz Eric Lott Ashwini Patki Jessica Pearce Josh Snow 10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow2

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.

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

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

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

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

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

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

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.

LEAN What? How? What helps ? Conclusion

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

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

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

LEAN – How? (Six steps) 1.Value – Who is the customer? 2.Value Stream – What is the service or product being provided to the customer? 3.Flow – Did the team identify the non-value added distances traveled by parts? 4.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. 5.Perfection - Optimize your process for what you are trying to achieve. 6.Replication – Can this process improvement be replicated in other parts of the business.

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

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

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 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) ( sp) sp Implementing 6sigma: “Black Belt” = organize of Six Sigma project “Green belt” = implement and monitor the project.

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. 10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow20 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.

TQM Process/Benefits Process begins by listening to customers' wants and needs and then delivering goods and services that fulfill these desires. 10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow21 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 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

What is Kaizen? Philosophy/practices focusing on continuous improvement in manufacturing activities, business activities, & 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. 10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow22

Kaizen Cycle The cycle of kaizen activity can be defined as: Standardize an operation Measure the standardized operation Gauge measurements against requirements Innovate to meet requirements and increase productivity Standardize the new, improved operations Continue cycle add infinitum 10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow23

Kaizen 10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow24 Elements Teamwork Personal discipline Improved morale Quality circles Suggestions for improvement 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

Other BPR Methods PDSA – Plan, Do, Study, Act Clinical Microsystem Model Talent Profiling 10/1/201525Group 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? 10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow26

The PDSA Cycle 10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow27

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 10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow28

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 10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow29

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) 10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow30

Talent Profiling Worker rather than Process Right Person – Right Job Important Characteristics to be Successful 10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow31

Project Management Methodologies (Traditional) Waterfall Spiral Build and Fix

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

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

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

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

Project Management Methodologies (Agile) Scrum Six Sigma Lean

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

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

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) 10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow40

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. 10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow41

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 10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow42

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. 10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow43

10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow44 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),

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 10/1/2015Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow45

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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. 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, 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, Six Sigma. Retrieved from Six Sigma - What is Six Sigma? Retrieved from ValueBasedManagement.com. Kaizen Philosophy and Kaizen Method. Retrieved from: