C A L I FOR N I A H EALTH C ARE F OU NDATION Better and Faster: How Safety-Net Providers Are Redesigning Care January 2011 Better and Faster: How Safety-Net Providers Are Redesigning Care Prepared for California HealthCare Foundation by Alexia Eslan, M.B.A. Callie L. Preheim John Snow Inc. (JSI) January 2011 About the Authors John Snow Inc. (JSI) is a consulting firm that works with organizations serving uninsured, under-insured, and at-risk populations. For more information on JSI, visit www.jsi.com. Alexia Eslan, M.B.A. Health Administration, is a senior consultant at JSI. She has a green belt in Lean Six Sigma. Callie L. Preheim is a project associate at JSI. About the Foundation The California HealthCare Foundation works as a catalyst to fulfill the promise of better health care for all Californians. We support ideas and innovations that improve quality, increase efficiency, and lower the costs of care. For more information, visit us online at www.chcf.org. ©2011 California HealthCare Foundation Contents 2 Introduction 2 Methods Used by Safety-Net Providers Lean Method Lean Six Sigma Patient Visit Redesign Process Reengineering Optimizing Primary Care Collaborative 9 Conclusion 1 1 Endnotes Safety-net providers can take Introduction Health care reform promises changes in the health care safety net, advantage of the momentum created including funding incentives for high-quality, patient-focused care; by health reform to improve clinical meaningful use of electronic health records (EHRs); and expanded services to accommodate the many newly insured Americans. outcomes, place patients at the center As health insurance exchanges become a reality, consumers will of their care, and eliminate waste. increasingly drive expectations and value, forcing health plans to adjust their pricing and coverage in order to compete. In this new marketplace, providers will need to systemize, organize, and find creative ways to provide more comprehensive and cost-efficient care. This issue brief highlights innovative management and process reengineering efforts that safety-net providers are using to respond to increasing demands for quality and efficiency. Management and process reengineering have transformed many industries, including manufacturing, transportation, and food. “These industries have used management engineering to optimize scheduling, staff at levels that match demand, and reduce waste in production processes,” noted David Belson in his March 2010 issue brief on improving efficiency in the safety net.1 The health care sector has been slow to embrace management and process reengineering, especially within the safety net, where there are fewer resources to make the initial investment and little technical support. However, this has begun to change as other industries have demonstrated improved outcomes and some federal and state financial support has become available. Methods Used by Safety-Net Providers This paper looks at a number of safety-net organizations that have adopted Lean, Six Sigma, patient visit redesign, or process reengineering using quality improvement tools such as the Institute for Healthcare Improvement’s Plan-Do-Study-Act (PDSA) model. More than 25 safety-net practices across the country were examined and 15 in-depth interviews were conducted. Select reengineering methods and experiences of these safety-net organizations are described below. 2 | C alifornia H ealth C are F oundation Lean Method Annually, FHCN serves 101,967 patients — half of Lean emphasizes reducing waste, developing smooth them farmworkers — and handles 492,683 patient workflow, and creating a culture that is responsive to encounters. The organization has 450 clinical patient needs.2 Originally developed at Toyota, it is support staff, 88 clinicians, and 14 dentists. also successful in health care. Teams are created and Family HealthCare Network implemented the champions identified across the organization. Tools Lean method in 2008 to eliminate waste from its are used to map out processes, identify issues, and processes relative to the patient’s experience. Lean’s solve problems. They include: five-step approach, shown in Figure 1, was used to help management, providers, and staff map processes ◾◾ Value stream mapping. This is used to analyze and analyze how they could be more efficient and the flow of materials and information required patient-centered. to bring a product or service to a client, and to determine which steps add value for the end user. It can be used in any process that needs Figure 1. ean’s Five-Step Approach L improvement. ◾◾ Line and self balancing. Line balancing focuses on evenly distributing work activities and 5. Perfect and 1. Identify value responsibilities to ensure there is no wasted time. reevaluate flow Self balancing analyzes the process by which employees “pull” information or material from each other. 2. Track processes; ◾◾ 5S — Sorting, simplifying, sweeping, 4. Patients gain trim steps standardizing, and sustaining. This five-step value from flow technique is used to reduce errors, promote safety, and facilitate maintenance of processes. 3. Improve staff ◾◾ 3P — Production, preparation, process. While and patient flow some Lean methods take the production process as a given and try to improve it, 3P focuses on eliminating waste through product and process design. FHCN focused on finding value-added steps and decreasing wait time and cycle time (the total Following are case examples of two organizations duration of a patient’s visit). To start the process, a that are successfully using Lean. team of about 20 front-line staff was initially guided Family HealthCare Network (FHCN) is a by a consultant and Lean expert. Federally Qualified Health Center (FQHC) with The team used Lean to improve the patient 13 sites (11 clinical, two administrative) serving experience, including reducing paperwork, Kings and Tulare counties in California’s agricultural which resulted in increased patient satisfaction. Central Valley region.3 It was founded in 1976. Next, Lean was used to implement an electronic Better and Faster: How Safety-Net Providers Are Redesigning Care | 3 health record (EHR) system in March 2010. This throughout the organization. Currently, Lean is was accomplished without negatively affecting supported by savings achieved through reduced waste productivity. Currently, FHCN is using Lean tools to and increased productivity. DHHA contracts with a become a patient-centered medical home (PCMH). consulting firm to help with ongoing Lean training The main challenge for FHCN was the initial and implementation. staff buy-in for Lean and, later, for the EHR The Lean 3P method was used very successfully implementation. Once providers and staff got to facilitate DHHA’s design and building of three involved and realized the benefits of both systems, patient-focused and less costly new community they became excited and committed to the Lean health centers. Leaders collaborated with staff, approach. Cultivating buy-in at all levels of the providers, architects, and the construction company organization was essential for success. “There is a to eliminate extra steps and create buildings that strong culture of change at FHCN,” said Jay Kelley, enable efficient patient, staff, and provider flow. chief information officer. “Lean opened everyone up DHHA believes the leadership and culture of to the idea that there is a better way that will be more each of its individual clinics influence the success efficient and better for the clients/patients. The Lean of the Lean efforts. The biggest challenge has been process assisted in opening doors and minds, which spreading best practices from one clinic to another. will make it a lot smoother for the medical home Lessons learned are disseminated throughout the implementation process.” DHHA system, and then teams at each clinic or Denver Health and Hospital Authority department tailor them to fit the culture and needs of (DHHA), an FQHC and hospital system in their patients, staff, and providers. Colorado, provides care for uninsured patients in Denver and surrounding areas.4 Approximately Lean Six Sigma 150,000 people — a quarter of all Denver residents —  Six Sigma is an approach to operations and quality receive care at Denver Health, and one in every three improvement that emphasizes controlling variability, children in Denver is cared for by Denver Health identifying causes for defects, and developing a group physicians. of trained change leaders. Like Lean, the approach DHHA started implementing the Lean method was developed for manufacturing but works well in in 2006 to address inconsistencies and waste health care. Six Sigma uses tools such as cause-and- throughout its system. Lean was chosen because it effect diagrams and statistical run/statistical process seemed more intuitive than other methodologies. control charts to identify and reduce variability. Denver Health first focused on its community health Lean Six Sigma combines the Lean and Six centers and then expanded Lean to its inpatient and Sigma methodologies. It is a structured discipline specialty care sites, where Lean activities are still in that enables organizations to conduct activities that their early stages. The most successful outcomes are valuable to customers, eliminate activities that to date have been achieved in community health, don’t add value, and reduce variability. In health revenue cycle, and inpatient flow. care, customers are typically defined as members/ A grant from the Agency of Healthcare Research clients, insurance companies and other funding and Quality (AHRQ) funded the first six Lean organizations, employees at all levels, and businesses facilitators and helped DHHA implement Lean that tie them together. 4 | C alifornia H ealth C are F oundation A group, department, or entire organization can went through the patient visit redesign process in use the Lean Six Sigma tools to move through the 2000, at a time when patients faced long waits to see transformation process. In a logical flow, data are a provider. The redesign identified issues that caused moved from one tool to another so there is synergy delays and prevented patients from moving smoothly among the tools, which enhances problem resolution through the clinic. These issues included a lack and the ability to sustain improvements. High- of communication among staff, poorly supported quality results require leadership commitment and providers, and patient-flow confusion. Staff created involvement of the entire team in the process. an ideal visit model and tried various iterations Although non-safety-net organizations such of the flow until a final model was developed and as Kaiser Permanente are successfully using Lean implemented in the clinic. Six Sigma, among the safety-net organizations In the ten years since the transformation, certain interviewed for this report, none had fully and design changes, such as creation of a client advocate successfully employed the Six Sigma or Lean Six position, have become integral parts of the clinic’s Sigma methods, because of their complexity and the culture. Patient satisfaction has increased and the need for advanced statistical knowledge. Safety-net clinic sees more patients. However, the redesign practices and clinics could better use Lean Six Sigma techniques initiated in 2000 were never fully once they establish a strong culture of change and integrated into the clinic’s processes, partly because general understanding of process-improvement tools. of high staff turnover. The absence of a permanent cultural change in policy, procedure, and workflow Patient Visit Redesign has eroded some of the initial progress. Patient visit redesign (PVR) focuses on minimizing High Plains Community Health Center is an unnecessary patient movement and streamlining FQHC in rural southeastern Colorado.7 The clinic patient flow.5 The goal is to virtually eliminate offers primary care, dental care, and behavioral waiting time. By decreasing patient cycle times, a health services to communities in four counties. clinic can increase its efficiency and the number of To increase clinic capacity and meet demand, High patients it sees in a day. This, in turn, can lead to Plains underwent Coleman and Associates’ PVR better patient and staff satisfaction and improved transformation in 2001. A team of five led the effort financial viability. PVR requires the practice to with support from Jay Brooke, High Plains’ executive look at the way it accomplishes work by starting director. After a period of training, observation, and from scratch to create a patient visit process that patient tracking, the clinic streamlined its workflow is efficient and patient-focused. The three safety- by reducing wasted time (such as in the waiting net organizations described below used Coleman room), implementing same-day scheduling, and Associates’ Patient Visit Redesign process to assigning two medical assistants to each provider, transform their practices. assuring adequate coverage and defined responsibility. Albuquerque Health Care for the Homeless Staff and patients converted to the new model (AHCH) is a Federally Qualified Health Center in with some difficulty, but after the transition was urban New Mexico.6 AHCH offers primary care, complete they became accustomed to the redesigned including medical, dental, and behavioral health clinic flow and embraced its benefits. Cycle times services, and residential programs. The organization dropped significantly and patient outcomes Better and Faster: How Safety-Net Providers Are Redesigning Care | 5 improved. Leadership has remained constant While the redesign helped Jackson improve its and many of the redesign principles have been financial situation and increase patient numbers successfully integrated into the clinic, which is now and system efficiency, not all of the redesign working to become a patient-centered medical home. principles have been fully integrated into the Jackson Health System (JHS) is a large, urban, culture. Leadership turnover and reduced emphasis academic health system located in Miami and on the PVR process diminished the importance of the surrounding metropolitan area.8 It consists of the transformation, and many elements have not hospitals and residency programs, community health endured. centers, and primary and specialty care clinics. JHS began the patient visit redesign process in 2004, at a Process Reengineering time when Jackson Health was experiencing financial The two safety-net providers described below have trouble — making the transformation process more transformed their practices over the past few years difficult while increasing the pressure to succeed. with process reengineering. Each of these short case JHS focused on outpatient visits; attracting a wider studies highlights the techniques they used, including client base, including insured patients; shortening the Institute for Healthcare Improvement’s Plan- patient cycle times; and increasing patient and staff Do-Study-Act Cycles and quality improvement satisfaction. initiatives. A train-the-trainers program was implemented Ammonoosuc Community Health Services to ensure staff understanding and compliance. (ACHS) is an FQHC and National Committee for Staffing models were examined and redesigned, and Quality Assurance (NCQA)-certified Level 3 patient- unnecessary positions were eliminated. Patient cycles centered medical home with five locations in rural were trimmed of unnecessary time spent waiting or New Hampshire.9 Originally established as a Title with providers, thus allowing providers to see more X family planning clinic in the 1970s, ACHS has patients per hour. become a successful FQHC and integral health care Sandy Sears, then-senior vice president for services provider in its communities. ambulatory services and community health, led the Edward D. Shanshala II was hired by the clinic transformation. She kept redesign in the forefront in 2005 as chief operating officer and became CEO through consistent and continuous messaging, in 2008. Using process reengineering techniques, he signage, and communication. Despite these efforts, was able to positively transform the clinic. ACHS the process was particularly difficult for staff, some streamlined its processes by examining and refining of whom didn’t understand why JHS was making its management and financial procedures, optimizing changes and eliminating positions. Once the redesign expenses and revenue stream, leveraging group became more fully integrated, however, staff saw purchasing, and moving toward self-directed sites positive results and many became proponents of the and pay for performance. In its care delivery process, process. In addition to reduced cycle times, increased ACHS uses patient navigators to guide patients patient numbers, and improved patient outcomes, through their health care experiences. A navigator’s benefits included lower staff absenteeism and role is to focus on the patient’s journey, not simply improved productivity. on case management. This allows patients to steer their own course, with the aid of the navigator. 6 | C alifornia H ealth C are F oundation The redesign practices implemented at ACHS the EHR, Clinica became part of the Integrated involved a period of transition before they were fully Physician Network — a group of about 20 practices accepted and integrated. Hiring and salary freezes that purchased their EHR together — to reduce costs. caused strain for employees and the organization, and Clinica also participates in the safety-net medical most of the funding for the changes came from the home initiative through the Colorado Community organization’s already-tight budget. Reengineering Health Network, which helps Clinica implement efforts were funded, in part, by a grant from the and measure PDSA cycles to continuously improve New Hampshire Endowment for Health. However, its practices. In addition, Clinica is part of the during and after the transition, the redesign paid Patient Safety and Clinical Pharmacy Services for itself and proved successful. Patient cycle times Collaborative through the Health Resources and have decreased, collections have increased, clinics are Services Administration. Through this collaborative, financially stable, clinical outcomes have improved, its staff is conducting anti-coagulation group visits and both staff and patients are more content. in partnership with the University of Colorado Reengineering processes and the PCMH pharmacy; students rotate through one of Clinica’s transformation are integral parts of Ammonoosuc sites to conduct point-of-care testing as well as Community Health Services’ culture and vision, educate patients about proper use of warfarin. This and staff at all levels are engaged. By improving its initiative has been very successful. processes, ACHS has been able to focus even more Patients are an integral part of the transformation on its patients. process, participating in committees and Clinica’s Clinica Family Health Services is an FQHC board of directors. Quarterly patient satisfaction serving the areas surrounding Boulder and Denver, surveys track which changes have positive effects. Colorado.10 Its patient base is predominantly the A major lesson learned for Clinica has been the working poor, the uninsured, and patients receiving importance of minimizing the number of process Medicaid benefits. improvement initiatives it employs at any given time. Clinica has been implementing process Currently, Clinica is emphasizing access and diabetes. improvement for the past ten years. It used Process reengineering has helped Clinica focus on PDSA cycles and quality improvement plans to patients and patient safety, especially regarding institutionalize a culture of process improvement medications. throughout its clinics. It also employed PDSA techniques to implement an electronic health record Optimizing Primary Care Collaborative in 2005 and e-prescribing at the beginning of 2010, The California Primary Care Association and to become an NCQA-certified Level 3 PCMH Optimization Initiative, supported by the Bureau in September 2010. Each of its four clinics has a of Primary Health Care and facilitated by Mark PCMH team with mixed clinical and non-clinical Murray and Associates, was launched in April 2007. representation. Annual surveys of staff and providers Structured as a one-year learning collaborative measure their satisfaction with Clinica and process and based on the Care Model, the Model for improvement initiatives. Improvement, and the Learning Model, it was Collaboration is key to Clinica’s success, designed to reduce delays in access to care in according to its leaders. Prior to implementing primary and specialty care settings, reduce delays at Better and Faster: How Safety-Net Providers Are Redesigning Care | 7 appointments, improve clinical care with a special increase the total number of patients from 12,500 focus on cancer prevention, and raise provider in 2007 to 15,000 in 2008. In addition, there have and staff satisfaction. The subsequent initiative, been increases in patient satisfaction and patient/ Optimizing Primary Care Collaborative (OPCC) provider continuity; a decrease in cycle time; better for Federally Qualified Health Centers, with goals productivity and access; and improved provider similar to the 2007– 08 collaborative, was launched retention. in April 2008.11 Several FQHCs participated, but few Managing change was a significant challenge for successfully sustained implementation and benefits. PHC when too many changes were made at once The efforts of two of the successful FQHCs are and staff and providers did not have time to adapt highlighted below. or see the benefits. The clinic resolved this problem Petaluma Health Center (PHC) is an FQHC in a number of ways. They are careful to keep that serves approximately 15,000 patients annually in providers in the loop regarding their panel size and Northern California’s Petaluma area.12 Fifty percent productivity, as well as to keep provider schedules of its patients speak Spanish; of these, 35 percent consistent (15-minute appointments for all family need health care services delivered in Spanish. Ninety medicine providers). PHC tracks productivity in an percent live below 200 percent of the federal poverty Access database to help give providers perspective on level. All providers are bicultural and bilingual in their patient load. English and Spanish. “It is hard to imagine ever going back to the In 2007, PHC implemented the Optimizing other type of care,” said Dr. John Pendleton, Primary Care (OPC) Initiative as part of the OPCC. associate medical director. “Waiting two weeks for an The clinic dedicated a multidisciplinary team to appointment, triage, and a lot of strategies that keep implement and sustain optimization of patient patients out when they want to be seen is dangerous. flow throughout its primary care and gynecology Seeing people when they want to be seen should be departments. This team dedicates an average of four the standard. Daily, weekly, and monthly you need to eight hours a week to OPCC-related work. to match the demand,” he said. “Looking forward is PHC also participates in the Culture of Quality very important.” Series developed by a local consortium. The series Mission Neighborhood Health Center focuses on teaching staff, providers, and management (MNHC) is a 39-year-old FQHC that serves more about PDSA cycles, quality improvement, and than 13,000 patients and handles some 66,000 visits evaluation. The clinic has approximately 75 annually.13 It focuses on providing culturally and ongoing PDSA cycles (half focus on performance linguistically competent health and human services improvement and half on quality measures). In for Latinos in San Francisco and the greater Bay Area. addition, PHC implemented electronic health Although MNHC has conducted many records in November 2009. small process redesign efforts, participation in The clinic has had a number of successes from its the Optimizing Primary Care Collaborative is participation in OPCC and the Culture of Quality its first organization-wide initiative. It began Series, including a new organizational culture that implementing the principles of OPCC in April 2010; is open to change and a decrease in the number implementation is expected to last one year. MNHC of visits per patient — which enabled PHC to is focusing on patient-centered communication, to 8 | C alifornia H ealth C are F oundation be measured through patient satisfaction surveys with ◾◾ Leadership. Support, continuous communica­ an emphasis on the qualitative aspect of the data. The tion, and involvement of leadership are essential center is engaged in educating staff and providers to success. Leaders can demonstrate engagement on patient-centered care and communication. A in many ways, including attending meetings, consultant will provide training on motivational participating in committees, and communicating interviewing, agenda setting, patient/provider continuously via email, newsletters, in person, relationships, team huddles, survey forms for and even in videos, as well as supporting decisions patients, and greeting patients warmly. by providers and front-line staff. MNHC has started using new techniques ◾◾ Baseline measures. Determining baseline data learned with PDSA cycles and is closely evaluating before undertaking process improvement helps the outcomes. It plans to disseminate new strategies measure gains. Seemingly small changes can make throughout the organization in 2011. big differences in the overall transformation of There have been challenges to implementing the practice. these changes in a multidisciplinary FQHC with many part-time providers, especially within family ◾◾ Implementation continuum. Before medicine. MNHC has high provider turnover; implementing a patient-centered medical home, because the clinic serves a transient population, it electronic health records, or other system of can be difficult for providers to establish long-lasting care, it is important to identify a proven process- relationships with patients. improvement methodology (such as patient visit redesign, Lean, or Six Sigma) to streamline Conclusion existing practices. The safety-net organizations highlighted in this issue ◾◾ Sustainability. The likelihood of sustainability brief demonstrate that, despite the many challenges, is increased by: savings achieved through proven management and process reengineering management and process reengineering; methodologies help practices better serve their commitment from all levels of the organization; patients. Most of the practices interviewed saw external grants; and potential reimbursement better clinical outcomes; shorter visit cycle times; from state or federal agencies. and better patient, provider, and staff satisfaction. They also achieved an improved bottom line, not ◾◾ Tailored models. Models must be customized only in funding but in reduced absenteeism and for each practice. Applying best practices from increased productivity. Key lessons these safety-net other health care organizations and even other organizations learned include: industries is reasonable and recommended, provided they are reshaped to fit the needs of the ◾◾ Culture. A successful transformation requires a clinic’s specific population. permanent change in culture and way of thinking about systems of care. It takes time, resources, ◾◾ Focus and pacing. Implementing many changes and commitment at all levels to achieve this. at once hinders the process and frustrates staff Securing staff and provider buy-in can take time, and providers. Change must be incremental, but incremental positive results assist with this focused, and clearly communicated to everyone effort. in the organization. Better and Faster: How Safety-Net Providers Are Redesigning Care | 9 ◾◾ Collaboration. Working with other organizations is key to providing a full spectrum of services to patients. Collaboration increases the technical expertise of management, staff, and providers, and may ease the organization’s financial burden. With careful evaluation of existing practices and financial and skill-building assistance, safety- net providers can make changes in their practices that will have a long-term effect on the health care system. Safety-net providers can take advantage of the momentum created by health reform to improve clinical outcomes, place patients at the center of their care, and eliminate waste. As new funding options become available to expand the safety net and improve the quality of care, those providers that systemize, organize, and seek creative ways to provide more comprehensive and cost-efficient care will be rewarded.14 10 | C alifornia H ealth C are F oundation Endnotes 1. Belson, D. 2010. Improving Efficiency in the Safety Net: 10. Clinica Family Health Services. Personal communication Management Engineering Practice and Cases. California with Clinical Quality Manager Hilary Dryden, June 1, HealthCare Foundation (www.chcf.org). 2010. 2. Ridgeway, J. 2009. “Southeast Planning Region 11. White Mountain Research Associates, LLC. 2009. LEAN Health Care.” Minnesota Department of Evaluation of the Optimizing Primary Care Collaborative. Employment and Economic Development California HealthCare Foundation. (www.positivelyminnesota.com). 12. Petaluma Health Center. Personal communication with 3. Family HealthCare Network. Personal communication Kathryn E. Powell, CEO, and John Pendleton, associate with Jay S. Kelley, chief information officer; Steven L. medical director, August 3 and 17, 2010. Palmer, chief medical officer; and Norma Verduzco, 13. Mission Neighborhood Health Center. Personal project director-operations; August 2, 2010. communication with Medical Director Ricardo Alvarez, 4. Denver Health and Hospital Authority. Personal July 28, 2010. communication with Paul Melinkovich, director of 14. Kingsdale, J. 2010. “Health Insurance Exchanges — Key Community Health Services; Tricia Mestas, program Link in a Better-Value Chain.” New England Journal of manager at Westside Pediatrics; and Felicia Hill, program Medicine 362: 2147– 2150 (www.nejm.org). manager at Eastside Adult Clinic, July 16, July 29, and August 2, 2010. 5. Coleman Associates. Patient Visit Redesign: Success Stories (www.patientvisitredesign.com). 6. Albuquerque Health Care for the Homeless. Personal communication with Associate Director of Planning & Evaluation Anita Córdova, June 17, 2010. 7. High Plains Community Health Center. Personal communication with Executive Director Jay Brooke, June 2010. 8. Jackson Health Systems. Personal communication with Senior Vice President and Chief Administrative Officer Sandy Sears, Jackson North Medical Center, June 25, 2010. 9. Ammonoosuc Community Health Services Inc. Personal communication with CEO Edward D. Shanshala II, July 14 and August 4, 2010. Better and Faster: How Safety-Net Providers Are Redesigning Care | 11 C A L I FOR N I A H EALTH C ARE F OU NDATION 1438 Webster Street, Suite 400 Oakland, CA 94612 tel: 510.238.1040 fax: 510.238.1388 www.chcf.org