creating a culture of excellence at usf women's
TRANSCRIPT
Creating a Culture of Excellence at USF Women’s Health
WCBF Lean Six Sigma Healthcare SummitMay 2011
Louis C. Rhodes
Purpose: Introduce USF Women’s Health and its journey of transformation over the past 5 years
Learning objectives:• Identify cultural elements that support
transformative efforts• Describe application of Lean Six Sigma
techniques across various opportunities• Select actions to improve cultural acceptance of
transformation
Purpose and Learning Objectives
2
• Why does Lean Six Sigma work in some organizations and not in others?
• How does cultural acceptance and the ability of an organization to embrace change affect success or failure?
• How do you develop a continuous process improvement culture?
• What organizational change and development tools can be utilized to overcome barriers and resistance to change?
Key Questions/Issues
3
• Administrator, New York University (Department of Obstetrics and Gynecology)
• Graduate of United States Military Academy (BS Management – Engineering) and Xavier University (MBA)
• General Electric Certified Black Belt and Master Black Belt in Six Sigma and Lean
• Eleven years experience in Six Sigma, Lean, and Change Management roles:
• Two years chemical industry (Millennium Chemicals)
• Four years in healthcare equipment and service delivery (GE Healthcare)
• Five years academic healthcare (USF Health and NYU School of Medicine)
• Expertise in curriculum development and skills transfer to clients
Lou Rhodes, MBA, MBB
4
11:15 – 11:45
11:45 – 12:15
12:15 – 12:45
12:45 – 2:00
2:00 – 2:15
Agenda
Introduction
Who will get us there?
Where are we headed?
How will we get there?
Summary and questions
5
• Please introduce yourself including:• Name• Position
• As a group, describe expectations for this session.
Introductions and Expectations
6
• Housekeeping:• Restrooms• Safety
• Ground rules:• Informal environment• Interactive exercises• Break individually as needed• Maintain speed• Limit cell phone use• Anything else?
Housekeeping and Ground Rules
7
• “What does culture mean to you?”
Exercise: Defining Culture
8
• Corporate culture: A blend of the values, beliefs, taboos, symbols, rituals and myths all companies develop over time*
• The way people think• Actions and beliefs• Acceptance and non-acceptance of performance
* - From Entrepreneur.com
What cultural challenges do you experience?
Cultural Transformation
Current Culture
Desired Culture
Time and Effort
You are here!Gap
How do we close the gap?
9
Path: Operational management and
improvement
Elements of CulturalTransformation
10
People: Leadership and
change management
Plan: Strategy development and
execution
Where do Lean Six Sigma experts fit in?
Background of USF Women’s Health
11
• No state income tax• Reliance on real estate development as primary
industry and real estate taxes for primary source of revenue
• State university system reliant on public funds• State tuition levels held at very low levels• Continued pressure on reimbursement rates and
payer mix
Florida Government andEducational Environment
12
• Mission: To improve life by improving health through partnership, research, education and healthcare
• 3,500 team members of educators, staff, physicians, researchers
• Over 420 physicians, 135 allied health, and 70 nurse practitioners
• 2 new out-patient buildings with imaging and an ambulatory surgery center
• 500,000 outpatient visits• 33% of Best Doctors in Tampa Bay• $350 million enterprise• No university hospital
USF Health Overview
13
• 40 – 50 faculty (physicians)• 60 – 80 staff (managers, nurses, medical assistants,
administrative assistants)• Multiple practice locations and commitments:
• 2 out-patient offices• 5 out-patient clinics• Labor and delivery coverage (24/7)• Residency coverage
• ~14,000 out-patient visits and 4,000 deliveries (2005)• Full OB/GYN service availability and access to other
specialties• Limited focus on efficiencies, service, or brand image
Department of Obstetrics and Gynecology (USF Women’s Health)
14
People: Leadership and Change Management
15
• Focus on clinical training in medical and nursing schools
• Progression from clinical to leader responsibilities• Growing complexity and integration of healthcare
system• Recognition of need for:
• Leadership skills• Emotional intelligence• Business skills• Professionalism
The Need for Leadership inMedicine
16
Leadership Institute at USF
17
• Top talent• Progressio
n planning• Selection
process
• Top talent• Progressio
n planning• Selection
process
• Tailored classes• Personality evaluations• Mentoring• Team-based system
level projects
• Better leaders
• Bench strength
• Project delivery
• Better leaders
• Bench strength
• Project delivery
• Classes:
• Creating high performance teams
• Communication and influence
• Conflict management
• Effective coaching and counseling
• Strategy mapping
• Financial acumen
• Effective problem solving
• Systems thinking
• Streamlining flow
Content
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• Evaluation:• Myers-Briggs testing• Learning connection
inventory• Team based project:
• University level project• Diverse team• Operational mechanisms to
manage and monitor delivery
• Mentoring:• Personal mentor• Project mentor
• ~80 Graduates:• Promoted to Chairs, Assistant
Deans, and Associate Deans• Improved leadership skill sets• Increased knowledge of university
and associated systems• Delivered high impact projects in the
areas of:• Customer service improvement• New service launches• Throughput improvement• Faculty mentoring
Impact
• USF Women’s Health:
• 5 graduates• Interim Chair,
Chief Medical Information Officer, Assistant Dean
• Successful practices
19
Change Management
Q x A = EQuality of the Solution times Acceptance of the
Solution equals Effectiveness of the Solution
• Recognition of the need for treating change as a system and process
• Employment of tools and approaches to understand motivations
• Development of strategies to increase support for initiatives
20
Setting the Vision
Mobilizing Commitment
Sustaining Improvement
Creating the Need
Monitoring Progress
Unfreezing Stage
Change Stage
Refreezing Stage
• Opening people’s minds to change
• Stating the “good” that will be
• Bringing people along
• Eliminating slippage
• Confirming delivery of the “good”
Foundation: Leadership and Reinforcing Systems
Change as a Process
21
Exercise: What do physicians want? Not want?
22
• Respect
• Information
• Input on decisions
• Things-that-work
• Incentives
• Presence
• Inefficiency
• Time wasters
• “Small-mindedness”
• Bureaucracy
Want Not-Want
• Alignment of goals and incentives:• Tie of pay to financial performance of the practice
• Transparency:• Established metrics• Department reports• Individual reports
• Additive interactions with physicians and staff• On-site availability and regular communication• “Speaking their language”• Participation on initiatives and projects
Change Management at USF Women’s Health
23
Plan: Strategy Development and Execution
24
Strategy Cycle
EnvironmentEnvironment
Filter
Metrics
InitiativeInitiative
AnalyzeAnalyze DefineDefine AlignAlign LaunchLaunch ManageManage MonitorMonitor
Strategy Team
Deliver
Communicate
Develop Implement
Initiate
OpportunityOpportunity
Opportunity
Resources
25
26
STAKEHOLDERSWho can help or
hinder us
STAKEHOLDERSWho can help or
hinder us
ENVIRONMENTWhere have we
beenWhat is around usWho do we serve
ENVIRONMENTWhere have we
beenWhat is around usWho do we serve
MISSIONWhy we exist
VALUESWhat’s important to us
VISIONWhat we want to be
MARKET DIFFERENTIATORSWhat makes us different
STRATEGIC OBJECTIVESOur game plan
KEY PERFORMANCE INDICATORSHow do we know we have gotten there
DESIRED STRATEGIC OUTCOMES
STRATEGIC INITIATIVESWhat we need to do
ACTION PLANOur specific task plan
Abstract
Concrete
Strategy Development
26
Exercise: Threats vs. Opportunities
27
• Reduced funding for university
• Continued reductions in reimbursement
• University bureaucracy and slow speed of decision-making
• Loss of talent
• Leverage multi-practice availability
• Increase transparency on performance
• Manage brand image
• Increase operational efficiency
• Improve service delivery
Threats Opportunities
Customers What are their needs?What do we give them? Need to give
them?
High Risk Patient to Low risk patients
• Quality of Life• Health• Healthy Babies
• The best most comprehensive care
Disadvantaged Payers
• Compassion• The best care: Quality of Life,
Health, Healthy Babies
• We are “IT” in town• The best most comprehensive care
Referring Physicians
• Efficient quality care• Follow through• Expertise - experiences
• Continuum of subspecialty care• Experts• Quality• Efficiency? Fast turn around?
Medical Students/ Residents/ Fellows
• Continuum of care/learning – From high to low risk
• The best most comprehensive care• Experts - the best trainers• Exposure to continuum of care• Cutting Edge
Donors
• Meaning• Individual care • Affiliation with Winners• Make a difference
• 1st in outcomes, innovation, and care• Being winners• Experts• The best trainers and providers• Cutting Edge
Customers and Needs
• Provide local, national and international leadership in women’s healthcare, education, and research
• Deliver comprehensive, full spectrum healthcare services to women in a friendly, efficient, timely, effective, and compassionate environment
• Graduate leaders from our residency, fellowship, and faculty programs
Mission and Vision
In 2015, an article is written about USF Health OB/GYN including the following points:
• Top 10 programs ranked in U.S. News and World Report• Top 20 NIH funded programs• Delivering cutting edge comprehensive women’s healthcare services• Leading the way in friendly, timely, effective, efficient, and profitable
care• Leading outcomes in state
In 2015, an article is written about USF Health OB/GYN including the following points:
• Top 10 programs ranked in U.S. News and World Report• Top 20 NIH funded programs• Delivering cutting edge comprehensive women’s healthcare services• Leading the way in friendly, timely, effective, efficient, and profitable
care• Leading outcomes in state
29
Recognized Leaders in
Clinical Care
Efficiency and Customer Service
Excellence
Cutting Edge • 1st in New
Procedures• 1st in Discovery• 1st in Efficiency• Comprehensive
care
Profitability• Entrepreneurial
Academic Model• Cost Efficiency
• Recognized Leaders in Clinical Care:• Comprehensive services• Leading outcomes in state
• Cutting Edge: • University – Innovation – cutting
edge• Leadership being 1st
• 1st Outcome• Process Engineering
• Efficiency & Customer Service Excellence:
• Customer satisfaction (Patient, Referring Physician)
• Responsiveness and communication
• Thank you – confirmation• Attention to details• “Flawless execution”• “Service recovery”• Leadership being 1st
• Entrepreneurial:• In-house Management (Creativity)
• Recognized Leaders in Clinical Care:• Comprehensive services• Leading outcomes in state
• Cutting Edge: • University – Innovation – cutting
edge• Leadership being 1st
• 1st Outcome• Process Engineering
• Efficiency & Customer Service Excellence:
• Customer satisfaction (Patient, Referring Physician)
• Responsiveness and communication
• Thank you – confirmation• Attention to details• “Flawless execution”• “Service recovery”• Leadership being 1st
• Entrepreneurial:• In-house Management (Creativity)
Strategic Objectives
30
Strategic
Objectives
Short Term
FY2009 Initiatives
Mid Term
FY2010 Initiatives
Long Term
Initiatives
Recognized Leaders in Clinical Care
• Increase marketing efforts
• Publish outcome metrics
Cutting Edge• Grow Ultrasound
Services• Leverage EHR
• Improve Research processes
Efficiency and Customer Service
• Improve internal referrals
• Improve service levels
• Improve scheduling/call system
• Improve referring MD communication
Profitability• Improve charging• Improve coding
• Increase rates of reimbursement
• Create extra sources of revenue
Branding
Scheduling
Service
Strategic Initiative Timing
31
Event Participants Review Items Timing
Faculty Meeting
• Faculty, Leaders
• Strategic Initiative Report
• Quarterly (some metrics reported on a semi-annual basis)
Individual Meetings
• Faculty, Leaders
• Profit and Loss Review
• Semi-Annual
Department Celebration
• Faculty, Leaders
• Accomplishment Review
• Annual
Operating Mechanisms
32
Path: Operational Management and Improvement
33
Initiative Focus
34
• Initiatives at USF Women’s Health:• Improve
Generalist scheduling
• Brand USF Women’s Health
• Launch STEP (Strive to Excel Program) Team
OutcomesService
Excellence
Cost (or Profitability
35
Revenue Business Levers: Clinical Operations
Profitability = Revenue – Cost
Revenue = Direct Patient Revenue + Contracts + Research + Grants
Direct Patient Revenue = (Clinical Charges + Professional Charges) * Collection Rate• Increase collection rate • Improve payer mix• Increase reimbursement rate
Clinical Charges = Appt./Session * Sessions * $’s/Appointment * Appt. Fill Rate • Increase
sessions• Improve service mix• Increase billing
accuracy• Increase procedure
conversion rate
• Improve scheduling• Reduce no-shows• Improve referrals• Promote practice
Appt./Session = Session Length / Time/Appt.• Utilize all
available hours• Extend hours
• Eliminate constraints• Adjust practice
• Increase appts. per session
• Set minimum quantity
• Increase outreach to service consumers
• Increase development efforts
• Increase outreach to research consumers
• Increase conversion to procedures
35
Cost Business Levers: Clinical Operations
Profitability = Revenue – Cost
Cost = Salary and Benefits + Room Charge + Equipment Cost + Supplies
Salary and Benefits = Physician S&B + Clinical Staff S&B + Admin Staff S&B
• Maximize efficient use
• Maximize efficient use
• Eliminate obsolete supplies
• Maximize efficient use
• Eliminate unused equipment/contracts
• Concentrate on revenue support
• Reduce wasted activities
• Leave empty positions unfilled
• Reduce positions
• Reduce wasted activities
• Leave empty positions unfilled
• Reduce positions
Other salary and benefit actions:• Freeze salary increases• Reduce salary levels• Reduce benefits
• Maximize revenue production
• Reduce wasted activities
• Leave empty positions unfilled
• Reduce positions
36
Purpose and Relevance:Generalist Scheduling
• Purpose: To review the process for assigning OB/GYN Providers to service areas
• Relevance: Based on analysis, there are opportunities to:• Reduce Patient bumps• Level Provider demand on clinic resources• Increase visibility and availability of additional slots for
Providers• Decrease rework in clinical operations and systems support
37
Dr. Lynch requests scheduling issues from Faculty
IDX prints bump list
Faculty calls Dr. Lynch with scheduling issues
Provider profile of available days
Dr. Lynch identifies/ reviews contractual commitments
Dr. Lynch develops Generalist grid (providers and schedule)
Systems Support reviews grid and programs IDX
Scheduler schedules appointments in IDX
Systems Support flips/reschedules appointments
Patients overload system or Providers receive limited support
Limited pool
Restrictive templates
Limited responses
Clinic de-prioritized
Precedes availability
Patient Waiting
Last minute requirements
Clinic de-prioritized
Failure Points
Nurse Midwife Lead develops CNM grid (providers and schedule)
Multiple Grid routes
• Highly complex process subject to failure
• Decentralized Provider scheduling leading to sub-optimization
38
Measure: Scheduling Process Map
Process
People
MachineEnvironment
MetricsMaterials
Appointment Availability & Continuity
Individual Provider approaches to mitigating bumps
Late clinic cancellations
Minimal scheduling protocols (acuity)
No protected time for acute appointments
Limited guidelines on Provider availability
Unclear Provider selection by appointment type
Bumps placed as overloads
Multiple routes for Provider scheduling
Multiple scheduling algorithms
Half-day clinic schedules at multiple sites
Individualized Provider profiles
Decentralization of scheduling function
Multiple locations of service
Multiple service types (L&D, call, clinic)
Room availability
Staff availability
Provider Availability
High demand on Providers
Multiple Mission requirements Clinic de-prioritization
Patient description of complaint
Scheduler identification of acuity
No penalty for poor service
Complex Provider scheduling process requires multiple rework cycles and last minute coordination
Provider controls own availability
Shortage of Providers to Demand
Cascading failure: Clinic cancellations lead to bumps lead to overloads lead to lengthy waits and reschedules
Varying process routes result in confusion and Provider dissatisfaction 39
Analyze: Appointment Availability and Continuity Causes
0
500
1000
1500
2000
2500
3000
1Aug06 2Sep06 3Oct06 4Nov06 5Dec06 6Jan07 7Feb07 8Mar07
1HMT420/440/4502OB17Davis3IVF4F-2Back5Total
Sum of Arrived
Month
Scheduling Location
0
500
1000
1500
2000
2500
3000
1Aug06 2Sep06 3Oct06 4Nov06 5Dec06 6Jan07 7Feb07 8Mar07
1HMT420/440/4502OB17Davis3IVF4F-2Back5Total
Sum of Arrived
Month
Scheduling Location
0.7
0.75
0.8
0.85
0.9
0.95
1Aug06 2Sep06 3Oct06 4Nov06 5Dec06 6Jan07 7Feb07 8Mar07
1HMT420/440/4502OB17Davis3IVF4F-2Back5Total
Sum of Arrival %
Month
Scheduling Location
0.7
0.75
0.8
0.85
0.9
0.95
1Aug06 2Sep06 3Oct06 4Nov06 5Dec06 6Jan07 7Feb07 8Mar07
1HMT420/440/4502OB17Davis3IVF4F-2Back5Total
Sum of Arrival %
Month
Scheduling Location
Analyze: Arrival* Analysis
• 1800 – 2500 arrivals per month
• Relatively stable arrivals
• Some potential increases (among GYN practices)
• 70 – 83% arrivals/scheduled
• Bumps: 3 – 9%
• Same Day Cancels: 6 – 11%
• No-Shows: 6 – 7%
Arrivals
Arrivals/Scheduled
* - Arrival = Scheduled – (Bumps + Same Day Cancels + No Shows)
Data: Clinical Monthly Report (8/06 – 3/07)
40
Analyze: Provider Schedule
• 5 overloaded clinic spaces (<2 Rooms/ Provider)
• Multiple open spaces:• Primarily Wednesday
mornings (Grand Rounds)
• Scattered throughout rest of week (except Tuesdays)
• Utilization efficiency:• 420 available slots
• 254 slots utilized
• 60% slot efficiency*
• 3.47 rooms/Provider**
April
Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon420 Hoffman Hoffman Sayer Sayer Hoffman Hoffman Hoffman Hoffman Kelly440 Keefe Kay Hoyte Hoyte Parsons, A. Hochberg Hoyte Hoyte
Parsons, A. Parsons, A. Keefe Parsons, A.Hoyte
450 Connery Wyckoff Lynch Cox Cox Lynch Lynch BrumleyBrumley Davis Wyckoff
17 Davis OB McCord Connery Cox Lynch Davis Brumley Davis McCarthy BrumleyKelly Brumley Wyckoff Brumley McCord Davis KellyWyckoff McCord Brumley Wyckoff
McCord17 Davis HR Quintero Quintero Kontopoulos Quintero Kontopoulos Parsons, M. Kontopoulos
Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon420 Hoffman Hoffman Sayer Sayer Hoffman Hoffman Hoffman Hoffman440 Hochberg Kay Hoyte Hoyte Kay Parsons, A. Hochberg Parsons, A.
Keefe Parsons, A. Parsons, A. Kay Keefe450 Brumley Davis McCarthy Cox Connery
Spellacy Wyckoff Brumley
17 Davis OB Connery Connery Brumley Spellacy Davis Brumley Davis Kelly ConneryWyckoff Wyckoff Brumley Davis BrumleyKelly Brumley
Kelly17 Davis HR Quintero Quintero Kontopoulos Kontopoulos Kontopoulos Parsons, M.
Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon420 Hoffman Hoffman Sayer Sayer Hoffman Hoffman Hoffman Hoffman Kelly440 Hochberg Hochberg Hoyte Hoyte Parsons, A. Hochberg Hoyte Hoyte
Keefe Kay Parsons, A. Parsons, A. Kay Hoyte Parsons, A.Keefe
450 Brumley Lynch Cox Lynch Lynch Tebes TebesDavis McCarthy Wyckoff
Spellacy Brumley17 Davis OB Wyckoff Brumley Cox Lynch Tebes Brumley Davis McCarthy Brumley
Kelly Brumley Brumley Kelly Davis Kelly WyckoffSpellacy
17 Davis HR Quintero Quintero Kontopoulos Parsons, M. Kontopoulos Parsons, M. Parsons, M.
Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon420 Hoffman Hoffman Sayer Sayer Hoffman Hoffman Hoffman Hoffman McCord440 Keefe Kay Hoyte Hoyte Parsons, A. Hochberg Hoyte Hoyte
Parsons, A. Parsons, A. Kay Hoyte Parsons, A.Keefe
450 McCarthy Connery Connery Cox Hart Connery Lynch Tebes TebesBrumley McCarthy Davis Spellacy McCarthy Lynch Brumley
17 Davis OB Connery Brumley Cox Spellacy Tebes Brumley Connery Connery BrumleyMcCord Kelly Brumley Brumley Brumley Davis Davis Kelly McCordKelly McCord Connery Davis
17 Davis HR Quintero Quintero Kontopoulos Parsons, M. Kontopoulos Parsons, M. Parsons, M.
Morning Afternoon420 Hoffman Hoffman440 Hochberg Hochberg
Keefe Kay450 McCarthy McCarthy
Wyckoff TebesBrumley
17 Davis OB Tebes BrumleyMcCord McCordKelly
17 Davis HR Parsons, M.
30Monday
Friday23 24 25 26 27
Monday Tuesday Wednesday Thursday
Friday16 17 18 19 20
Monday Tuesday Wednesday Thursday
Friday9 10 11 12 13
Monday Tuesday Wednesday Thursday
Friday2 3 4 5 6
Monday Tuesday Wednesday ThursdayApril
Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon420 Hoffman Hoffman Sayer Sayer Hoffman Hoffman Hoffman Hoffman Kelly440 Keefe Kay Hoyte Hoyte Parsons, A. Hochberg Hoyte Hoyte
Parsons, A. Parsons, A. Keefe Parsons, A.Hoyte
450 Connery Wyckoff Lynch Cox Cox Lynch Lynch BrumleyBrumley Davis Wyckoff
17 Davis OB McCord Connery Cox Lynch Davis Brumley Davis McCarthy BrumleyKelly Brumley Wyckoff Brumley McCord Davis KellyWyckoff McCord Brumley Wyckoff
McCord17 Davis HR Quintero Quintero Kontopoulos Quintero Kontopoulos Parsons, M. Kontopoulos
Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon420 Hoffman Hoffman Sayer Sayer Hoffman Hoffman Hoffman Hoffman440 Hochberg Kay Hoyte Hoyte Kay Parsons, A. Hochberg Parsons, A.
Keefe Parsons, A. Parsons, A. Kay Keefe450 Brumley Davis McCarthy Cox Connery
Spellacy Wyckoff Brumley
17 Davis OB Connery Connery Brumley Spellacy Davis Brumley Davis Kelly ConneryWyckoff Wyckoff Brumley Davis BrumleyKelly Brumley
Kelly17 Davis HR Quintero Quintero Kontopoulos Kontopoulos Kontopoulos Parsons, M.
Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon420 Hoffman Hoffman Sayer Sayer Hoffman Hoffman Hoffman Hoffman Kelly440 Hochberg Hochberg Hoyte Hoyte Parsons, A. Hochberg Hoyte Hoyte
Keefe Kay Parsons, A. Parsons, A. Kay Hoyte Parsons, A.Keefe
450 Brumley Lynch Cox Lynch Lynch Tebes TebesDavis McCarthy Wyckoff
Spellacy Brumley17 Davis OB Wyckoff Brumley Cox Lynch Tebes Brumley Davis McCarthy Brumley
Kelly Brumley Brumley Kelly Davis Kelly WyckoffSpellacy
17 Davis HR Quintero Quintero Kontopoulos Parsons, M. Kontopoulos Parsons, M. Parsons, M.
Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon420 Hoffman Hoffman Sayer Sayer Hoffman Hoffman Hoffman Hoffman McCord440 Keefe Kay Hoyte Hoyte Parsons, A. Hochberg Hoyte Hoyte
Parsons, A. Parsons, A. Kay Hoyte Parsons, A.Keefe
450 McCarthy Connery Connery Cox Hart Connery Lynch Tebes TebesBrumley McCarthy Davis Spellacy McCarthy Lynch Brumley
17 Davis OB Connery Brumley Cox Spellacy Tebes Brumley Connery Connery BrumleyMcCord Kelly Brumley Brumley Brumley Davis Davis Kelly McCordKelly McCord Connery Davis
17 Davis HR Quintero Quintero Kontopoulos Parsons, M. Kontopoulos Parsons, M. Parsons, M.
Morning Afternoon420 Hoffman Hoffman440 Hochberg Hochberg
Keefe Kay450 McCarthy McCarthy
Wyckoff TebesBrumley
17 Davis OB Tebes BrumleyMcCord McCordKelly
17 Davis HR Parsons, M.
30Monday
Friday23 24 25 26 27
Monday Tuesday Wednesday Thursday
Friday16 17 18 19 20
Monday Tuesday Wednesday Thursday
Friday9 10 11 12 13
Monday Tuesday Wednesday Thursday
Friday2 3 4 5 6
Monday Tuesday Wednesday Thursday
* - Efficiency based on slot equal to 2 rooms
** - Based on 21 room availability per half- day 41
Issues:
• Multiple routes for scheduling adjustment into Systems
• Potential sub-optimization within Division
• Allowable last minute changes
• Last minute publication
• Loose controls on clinic adjustment process
Resolution:
• Single leader (and conduit for information to Scheduling Support)
• Schedule for 3 month period
• Publish two months ahead of schedule start
• Tighten process for clinic adjustments including space and patient considerations
42
Improve: Issues and Resolution
43
Improve: Simplify Appointment Types
• Streamlined appointment types (with elimination of redundant types)
• Set reasonable time periods for appointment length
Type Appointment DurationLOB Low Risk OB 15MOB Medium Risk OB 15HOB High Risk OB 20NOC New OB Corporation 30NOP New OB Practice 30PPE Post Partum Evaluation 15EPV Established Patient Visit 20AEP Annual Established Patient 20POV Post Operative Visit 20NPC New Patient Corporation 30NPP New Patient Practice 30EEP Established Procedure 30
43
44
Improve: Standardize Appointment Templates
• Set standard availability/mix of appointment types and order of appointments
• Leveraged system flexibility to fill appointments
Template: OBGYN Clinic Template: OBGYN ClinicAM session location: SC4 PM session location: SC4Session end time: 1200N Session end time: 500P
8:00 - 9:00 1:00 - 2:00LOB 4 MOB 4 HOB 3 LOB 4 MOB 4 HOB 3EPV 3 AEP 3 POV 3 EPV 3 AEP 3 POV 3
PPE 19:00 - 9:30NOC 1 NOP 1 Switch to any at 7 days out 2:00 - 2:30
NOC 1 NOP 1 Switch to any at 7 days out9:30 - 10:00NPC 1 NPP 1 Switch to any at 3 days out 2:30 - 3:00
NPC 1 NPP 1 Switch to any at 3 days out10:00 - 10:40EPV 2 AEP 2 POV 2 Switch to any at 3 days out 3:00 - 3:40
EPV 2 AEP 2 POV 2 Switch to any at 3 days out10:40 - 11:30LOB 3 MOB 3 HOB 2 Switch to any at 3 days out 3:40 - 4:10PPE 1 NPC 1 NPP 1 Switch to any at 3 days out
11:30 - 12:00 4:10 - 4:30EEP 1 Switch to any at 3 days out EPV 1 AEP 1 POV 1 Switch to any at 3 days out
44
45
Improve: Level-load Provider Schedules
SundayDivision/Group Provider Week HS AM PM HS AM PM HS AM PM HS AM PM HS AM PM HS
GEN Bruder 1 Gen Gen Cover Cover TGH CALL1 Cover CoverGEN Bruder. 2 Gen. Gen. Cover. Cover. PC. PC. CMS. CMS. Cover. Cover.GEN Burgess 1 OBG OBG PC-1/Cover-3,5 NH-1/Cover-3,5 TGH CALL2 PC PC/WH-1 Cover JE-3/Cover-1,5 L&D2 L&D2GEN Burgess. 2 Cover. Cover. Cover. Cover. SS-2/UA-4. Cover-2/Mors OR-4. Ke-2/Mors OR-4. OBG. OBG.GEN Connery 1 L&D2 L&D2 OB OB GYN TGH CALL2 PC PC OBG OBGGEN Connery. 2 L&D2. L&D2. OB. OB. GYN. TGH CALL2. PC. PC. TGH OR. TGH OR.GEN Cox 1 GYN-1,5/TGH OR-3 GYN-1,5/TGH OR-3 USF USF OB USF USF Mors OR-1,5/USF-3 Mors OR-1,5/USF-3GEN Cox. 2 USF. USF. USF. USF. USF. L&D2. L&D2. TGH CALL2. PC. PC.GEN Dileo 1 Cover Cover GYN GYN GYN TGH CALL1 PC PC GYN GYNGEN Dileo. 2 Cover. Cover. GYN. GYN. GYN. GYN. GYN. TGH OR. TGH OR.GEN Glazerman 1 MOR MOR MOR MOR MOR MORGEN Glazerman. 2 MOR. MOR. MOR. MOR. MOR. MOR.GEN Holmstrom 1 ACAD Lee Davis TGH CALL1 PC/Cover PC/Cover ACAD GYN TGH OR-1,5/Mors OR-3 TGH OR-1,5/Mors OR-3 GYN GYNGEN Holmstrom. 2 ACAD. Lee Davis. Cover. Cover. ACAD. GYN. TGH OR-1,5/Mors OR-3 TGH OR-1,5/Mors OR-3 GYN. GYN.GEN Klasko 1 OBGGEN Klasko. 2 TGH CALL1-4.GEN Kohl 1 GEN GEN GEN GENGEN Kohl. 2 GEN. GEN. GEN. GEN.GEN Lynch 1 TGH OR TGH OR GYN OB GYN GYN TGH CALL2 PC PCGEN Lynch. 2 TGH OR. TGH OR. GYN. OB. GYN. GYN. L&D2. L&D2.GEN Malina 1 OBG OBG TGH CALL2 PC/Cover PC/Cover L&D2 L&D2 TGH OR-1,5/Mors OR-3 TGH OR-1,5/Mors OR-3 USF USFGEN Malina. 2 OBG. OBG. OB. OBG. Cover. Cover. USF. USF. USF. USF.GEN Palmer 1 Research Research USF USF USF USFGEN Palmer. 2 Research. Research. Cover. Cover. USF. USF.GEN Patel 1GEN Patel. 2GEN Rao 1 Cover Cover L&D2 L&D2 OB OB OB OB OBGEN Rao. 2 OB. OB. TGH CALL2. PC. PC. OB. OB. OB. OB. OB.GEN Smith 1 GYN GYN OBG OBG TGH OR TGH OR OBG OBGGEN Smith. 2 GYN. GYN. L&D2. L&D2. TGH CALL2. PC. PC. OBG. OBG. Cover. Cover.GEN Spellacy 1 ACAD Lee Davis Jail OBG Gen TGH OR TGH OR Gen HRGEN Spellacy. 2 ACAD. Lee Davis. OBG. Gen. TGH OR. TGH OR. Gen HR.GEN Wyckoff 1 GYN GYN TGH OR TGH OR Cover Cover L&D2 L&D2 OBG GYNGEN Wyckoff. 2 GYN. GYN. TGH CALL1-2. PC. PC. GYN. GYN. OBG. GYN.CNM Brumley 1 GYN OB GYN OB CNM L&D CNM L&D Gen CNM Gen CNM OB OBCNM Brumley. 2 GYN. OB. GYN. OB. CNM L&D. CNM L&D. Gen CNM. Gen CNM. OB. OB.CNM Davis 1 USF USF GYN OB OB OB CNM L&D CNM L&D USF USFCNM Davis. 2 USF. USF. GYN. OB. OB. OB. CNM L&D. CNM L&D. USF. USF.CNM Jevitt 1 USF USFCNM Jevitt. 2 USF. USF.CNM Kelly 1 CNM L&D CNM L&D Gen CNM Gen CNM CNM L&D OBCNM Kelly. 2 CNM L&D. CNM L&D. Gen CNM. Gen CNM. CNM L&D. OB.CNM McCord 1 OB OB Gen CNM Gen CNM OB OB OB OB CNM L&D CNM L&DCNM McCord. 2 OB. OB. Gen CNM. Gen CNM. OB. OB. OB. OB. CNM L&D. CNM L&D.
Clinic Load Analysis: Maximum Week AM PM HS AM PM HS AM PM HS AM PM HS AM PM HSSTC Generalist/CNM 8 1 7 8 8 8 2 9 4 5 8 8STC Generalist/CNM. 8 2 7 8 7 8 2 8 7 8 6 6
USF 4 1 3 2 3 3 1 2 3 3 4 3USF. 4 2 3 3 3 3 0 2 2 2 5 4
Outside Load Analysis:Required Week AM PM HS AM PM HS AM PM HS AM PM HS AM PM HSTGH OR 2 1 2 2 4 4 1 1 2 2 2 2TGH OR. 2 2 3 3 3 3 1 1 1 1 4 4
TGH CALL1 1 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 0TGH CALL1. 1 2 0 0 0 0 0 1 0 0 1 0 0 1 0 0 0
L&D2 1 1 1 1 1 1 1 1 1 1 1 1L&D2. 1 2 1 1 1 1 0 0 1 1 1 1
TGH CALL2 1 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 0TGH CALL2. 1 2 0 0 1 0 0 1 0 0 1 0 0 1 0 0 0
Wednesday Thursday
Tuesday
Friday
FridayWednesday Thursday
Monday
Monday
Monday
Tuesday
FridayWednesdayTuesday Thursday
• Includes all Providers’ recurrent weekly schedules• Sums load in each clinical space and outside service
demands (except L&D and non-weekly requirements)• Color-codes availability, overfills, and shortfalls
Provider Names
45
46
Improve: Visually Manage Provider Schedules
• Published greater than 30 days before 1st day of month• Clearly identifies assignments for each Provider using
standard naming conventions
Month: April DRAFT1st of month is: WednesdayNo. days/month: 30
Monday -1 Tuesday 0 Wednesday 1 Thursday 2 Friday 3Provider AM PM AM PM AM PM AM PM AM PM
Bruder Gen Gen Cover Cover 0 0 L&D1 L&D1 L&D1 L&D1Burgess OBG OBG PC-1/Cover-3,5 NH-1/Cover-3,5 PC PC/WH-1 obg kelton vac vacConnery L&D2 L&D2 OB OB 0 GYN PC PC OBG OBG
Cox GYN-1,5/TGH OR-3GYN-1,5/TGH OR-3 USF USF 0 OB USF USF Mors OR-1,5/USF-3Mors OR-1,5/USF-3Dileo Cover Cover GYN GYN 0 GYN GYN GYN GYN GYN
Glazerman MOR MOR 0 0 0 MOR 0 MOR MOR MORHolmstrom ACAD Lee Davis PC/Cover PC/Cover ACAD GYN TGH OR-1,5/Mors OR-3TGH OR-1,5/Mors OR-3 GYN GYN
Klasko 0 0 OBG 0 0 0 0 0 0 0Kohl 0 0 0 0 0 0 GEN GEN GEN GEN
Lynch TGH OR TGH OR GYN OB pc pc GYN GYN PC PCMalina OBG OBG PC/Cover PC/Cover L&D2 L&D2 TGH OR-1,5/Mors OR-3TGH OR-1,5/Mors OR-3 USF USFPalmer 0 0 Research Research USF USF USF USF 0 0Patel 0 0 0 0 0 0 0 0 0 0Rao Cover Cover L&D2 L&D2 L&D1 L&D1 L&D2 L&D2 L&D2 L&D2
Smith GYN GYN OBG OBG 0 0 TGH OR TGH OR OBG OBGSpellacy ACAD Lee Davis Jail OBG 0 Gen TGH OR TGH OR Gen HR 0Wyckoff GYN GYN TGH OR TGH OR Cover Cover pc pc OBG GYN
Provider Names
46
47
Control: Daily Arrivals Baseline and Improved States*
Stage 1 (HMT/17D):
• Avg: 112.2
• Std Dev: 22.7
Stage 2 (STC):
• Avg: 111.1
• Std Dev: 27.6
Stage 3 (Schedule process):
• Avg: 127.5
• Std Dev: 14.5
* - Weekday arrivals, not including Wednesdays (7/2/07 – 10/9/07); n = 57
What’s changed?
• Assignment matrix maximizing space utilization
• New schedule process
• Nurse Manager filling open slots
47
15% increased volume and
reduced variation
48
Control: Benefit Calculation
• Average RVU’s per generic GYN appointment = 2.97*• Increase in appointments = 15.3 appointments per day
(Base line: 112.2 appt./day; Post-improvement: 127.5 appt./day)
• At $38/RVU x 2.97 RVU’s/appointment x 15.3 appointments/day x 200 work days per year (excludes Wednesdays) = $345K annual benefit
• Does not include added cost to service or downstream revenue (from procedures)
* - GYN arrivals at HMT 450 (7/3/06 – 6/29/07); n = 4482 48
Exercise: Broader Application
49
• Optimize physician group office schedule
• Improve assignment of OR block times
• Integrate multiple scheduling processes
Using these approaches, what broader potential applications exist within healthcare?
50
• Purpose: To develop a brand for USF Women’s Health and put it into operation
• Relevance: Taking control of and improving the brand will increase and improve the image of USF Women’s Health within the community leading to increased support, service delivery, and revenues.
Purpose and Relevance: USF Women’s Health Branding
50
51
Identify audience
Develop audience interests
Specify intended actions
Develop message
• Who do we need to reach?
Identify media
Specify routing
• What is important to them?
• What do they want that is difficult to get?
• What do we want them to do?
• What is it they need to hear?
• What will lead them to act?
• What is the message format?
• Where do we place our message?
• Patients • “Give me good care.”
• “Don’t waste my time.”
• “Spend time with me and listen to me.”
• Schedule for own and families’ care
• Broaden use of services
• Tell others about positive experiences
• Wide-range of services
• Top of the line care-givers
• Service-oriented care
• Brochure • Placement in USF Health clinics
• Placement in partner locations
Other customers:
• Donors
• Referring Physicians
• Students
Other media:
• Posters
• Mailers
• Calendar of events
Branding Design Process
52
Design: Promotional Materials
52
53
June 2009:
• Issue: Long lines at front desk
• Resolution: Additional check-in station and person, system for back-up support
Improve: Operational Actions
October 2009:• Issue: Poor access• Resolution: Increased support for
clinical messaging, adjusted lunch breaks, launched MS Office Communicator, instituted nurse training of schedulers
Count 6 4 3 3 5Percent 28.6 19.0 14.3 14.3 23.8Cum % 28.6 47.6 61.9 76.2 100.0
Complaint Group
Other
Long
Line
s at F
ront D
esk
Chec
k-ou
t Proce
ss at F
ront Des
k
Long
Wait
Tim
e to See
Doc
tor
Poor C
ommun
icatio
n
20
15
10
5
0
100
80
60
40
20
0
Count
Perc
ent
Pareto Chart of Complaint Group
Count 1 1 12 2 2 1 1 1 1 1Percent 7.1 7.1 7.114.314.314.3 7.1 7.1 7.1 7.1 7.1Cum % 85.792.9100.014.328.642.950.057.164.371.478.6
Complaint Category
14
12
10
8
6
4
2
0
100
80
60
40
20
0
Count
Perc
ent
Pareto Chart of Complaint Category
Patient Comment
Cards
Patient Comment
Cards
53
Improve: Service LineDevelopment
• Brings together:• Maternal Fetal Medicine• Neonatology• Pediatric Surgery
• Seamless service delivery through Nurse Coordinator
• Multi-disciplinary case evaluation
• Supported through regular outreach and communication
54
Improve: Design Principles and Realization
Design Principle
• Seamless movement among services
• Delivery of all services to target specifications reflective of needs of customers (referring physicians, patients)
• Clear communication among various services
• One stop shopping
Realization
• Patient navigator supports ease of movement; No reintroduction to central scheduling after entry
• Established and adhered to service standards including cycle times and quality
• Operational mechanism of weekly multi-disciplinary meeting; Care plan development and management; PRN emergency meeting
• Bundled service delivery; Completed follow-on service coordination and education during single visit; “Care to Patient” service model
55
Improve: Appointment Tiers
First Tier• Ultrasound• MFM• Neonatology• Tour of NICU
Second Tier• Pediatric
Surgery• Adult Cardiology• Pediatric
Cardiology• Additional Adult
and Pediatric sub-specialties
Third Tier• Anesthesia
• Second tier appointment types may be included in the first tier appointment based upon Patient Navigator determination
56
Scheduling forwards request to Patient Navigator
Scheduling forwards call to Patient Navigator
Physician/ CNM refers Patient to
MFM
Physician/ CNM office calls Patient Navigator
Patient Navigator receives request and initiates/ updates medical record
Patient Navigator contacts patient
Patient calls Scheduling
requesting an MFM appt.
Patient requests an
MFM appt. via USFH
website
Patient Navigator requests/ receives scans and test results
Patient Navigator completes information sheet and schedules appointment(s)1
week2 weeks
Patient arrives for appointment(s)
USFH Physician/ CNM refers Patient to
MFM
USFH Physician/ CNM completes referral form (“pinkie”)
Genesis Physician/ CNM refers Patient to MFM
Genesis Nurse coordinates MFM appointment through Patient Navigator
Improve: Patient Access Process Map
57
Exercise: Broader Application
58
• Establish organizational brand (promotional and operational aspects)
• Launch service lines (women’s health center, heart health) based on leveraging and coordinating multiple practices
Using these approaches, what broader potential applications exist within healthcare?
59
• Purpose: To identify and address customer service issues within USF Women’s Health through a staff and physician driven team
• Relevance: Staff and physicians, through their routine interaction with patients, are well positioned to identify and resolve service issues to increase customer satisfaction.
Purpose and Relevance: Launch STEP* Team
* - Strive to Excel Program
59
60
Measure: Employee Recognition Program
60
61
• Poor communication (28%)• Long Wait Time to See Doctor (19%)• Front Desk Check-out Process and Lines (28%)
Analyze: Patient Complaints*
* - STEP Program Patient Comment Cards collected 11/08 (n = 21)
Count 6 4 3 3 5Percent 28.6 19.0 14.3 14.3 23.8Cum % 28.6 47.6 61.9 76.2 100.0
Complaint Group
Other
Long
Line
s at F
ront D
esk
Chec
k-ou
t Proce
ss at F
ront Des
k
Long
Wait
Tim
e to See
Doc
tor
Poor C
ommun
icatio
n
20
15
10
5
0
100
80
60
40
20
0
Count
Perc
ent
Pareto Chart of Complaint Group
61
62
Count 8 1 1Percent 80.0 10.0 10.0Cum % 80.0 90.0 100.0
Compliment Group
Overall n
ice e
xper
ience
Appo
intmen
t on-
time
Exce
llent
Pat
ient
service
- Be
havio
r
10
8
6
4
2
0
100
80
60
40
20
0
Count
Perc
ent
Pareto Chart of Compliment Group
Top issues:• Excellent Patient service -
Behavior (80%)
Analyze: Patient Compliments*
* - STEP Program Patient Comment Cards collected 11/08 (n = 10)
Secondary issues:• Appointment on-
time, Overall nice experience (20%) 62
63
Improve: Error Proof Scheduling Location
Check screen added to confirm alternative location
63
64
Improve: Clinic Status Updates
64
Exercise: Broader Application
65
• Launch employee recognition program
• Set-up service metrics with linked improvement activities
• Initiate service standards
Using these approaches, what broader potential applications exist within healthcare?
Impact
66
Outpatient Volume
• Increased outpatient visits ~150% over 4 years (’05-’09) with associated revenue*
• Improved schedule regularity and provider satisfaction
• Reduced bumps with associated patient frustration and rework
-
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
FY2000
FY2001
FY2002
FY2003
FY2004
FY2005
FY2006
FY2007
FY2008
FY2009
FY2010(proj)
0
5
10
15
20
25
30
Visits
South Providers
* - Increase in South Providers by 42% (from 19 to 27)67
Other Metrics
• Went from losing $1M per year to making $1M per year
• Easier discussions regarding salary increases, bonuses, and purchases
• Increased patient satisfaction
• Being listened to
• Responding to their issues
• Increased appointment availability
• Better scheduling processes
• Reduced appointment bumps
• Standard brand appearance and improved recognition
• Improved relationships with affiliated hospital and other departments (pediatrics, surgery)
68
Thank you for your time.
Questions?
69