Achieving Quality in Healthcare –A Strategic View
Dr. Ninfa Saunders
10th Annual Lean Six Sigma and Process Improvement in Healthcare Summit
May 11th, 2011
Affordable Care Act 2010
Is….∼ An Insurance Reform
∼ Expansion of coverage
∼ Defers Medicare Part A insolvency until 2026
Is Not….∼ A Health care delivery and organization reform
New Era: Challenges & Realities
New employment: slow & painful
Changing reimbursements landscape
Bundling of payments
Accountable Care Organizations
Management of Population Health
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Pay for Performance
Upto 7% of Medicare payments are at risk
2010 2011 2012 2013 2014 2015 2016 2017
Value Based Purchasing
1% 1.25% 1.5% 1.75% 2%
2%
Readmissions
Hospital Acquired Conditions
Meaningful Use
Reporting of Quality Data
3%
1%
1%
2%
1% 2.0% 3.0%
1.0%
1.0%
Value Definition for Hospitals: Pre‐Reform
Bed Mgmt
LOS Mgmt
Labor Cost Mgmt
Clinical UtiliznMgmt
Balance Sheet Mgmt
Hospitals in the New Era
Smart Growth Value Systems
of Care
Source: Sg2
Value Definition: Differ by Stakeholders
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Value: New Era
Quality
Cost
Experience
Access
Evidence based
Higher quality & efficiency than peer organization
Manage within cost constrain set by purchaser
Outstanding patient engagement
Virtua’s Continuum of Care
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Virtua Memorial Hospital, Mt. HollyVirtua Marlton Hospital Virtua Berlin Hospital
Virtua Voorhees Hospital
4 Acute Care Hospitals: Berlin, Marlton, Mount Holly, Voorhees
2 Major Outpatient Centers: Camden & Washington Township
2 Long‐Term Care Facilities: Berlin, Mount Holly
2 Home Health Services: Camden & Burlington Counties
5 Ambulatory Surgery Centers: Voorhees, Mount Holly, Medford, Sewell (2)
2 HealthFitness Centers: Voorhees & Washington Township
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Located in highly competitive Delaware Valley metropolitan area
More people in Southern NJ choose Virtua than any other health system or hospital *
• 214,228 Emergency Department Visits• 56,619 Admissions• 7,689 Births• 255,471 Outpatient Visits• 170,732 Home Health Care Visits
Largest health care provider in Southern NJ and one of the largest in the state *
• 8,400 Employees• 1,800 Physicians• 140 Employed Physicians
* 2009 statistics
Virtua is the Market Leader
1998Merger of two health systems:
Virtua
2000“We are an average organization” – beginning
of our quality journey to excellence
2010Virtua is a multi‐faceted, sophisticated and advanced regional healthcare organization
Virtua’s Journey from Average to Excellence…
Virtua Health’s Roadmap: Achieving Value
Present Immediate Short term Mid‐term Long term
Integrate…………….Re‐design• Care delivery
Standardize• Quality & CostsFocus
Prelude Post‐reform era
MarketExpansion
Reform
Key to Achieve Value: Virtua Health
Results
People
Process
Strategy
Achieving Value: Virtua
Identify, verify & report
performance metrics
Identify & prioritize core work systems
Identify variations in care ‘value’
Identify critical factors
leading to value
Identify operations
improvement opportunity
Identify care model redesign
opportunities
Data are “Front & Center” in Healthcare Reform
“…if you really want to transform health care, you
basically build a sort of health care economy around
the data that relate to people…data becomes a
central asset in trying to figure out how you would
improve every aspect of health care…costs for
providers and patients and improve quality of care.”
Craig Mundie, Microsoft and Eric Schmidt, Google
Presidential Task Force to reform American HealthCare
Source: The Economist, “Data, Data Everywhere”, February 27th, 2010
Clinical Intelligence Capabilities are Key to Healthcare Reform
• $175M+ likely opportunity• Payments starting in 2012 for “meaningful use”• Penalties start in 2015 for non‐compliance
Health IT
• Evolution of evidence‐based medicine• Elimination of unnecessary variation• Appropriate standardization of care• Foundation for value‐based payment
Clinical Intelligence/ Comparative Effectiveness Research
• Bundled payments & Value‐based payment• Readmission penalties• Primary care/medical home• Chronic coordination
Payment Alignment
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Create Data Manage DataDefine
Information Requirements
Create Report Analyze Information
React to Information
Enterprise AnalyticsEnterprise Analytics Enabling Business Transformation
Capture → Assemble→ Analyze→ Integrate→ Educate→ Transform
Transparency of Metrics
Five Major Components of “Enterprise Analytics”
• Data Accountability• Strategic Views • Analytics Training
• Data Stewardship
• Data Governance Model
• Automated Data Validation• Certified DataMarts• Clinical Collaboration
• Enterprise Data Usage
Creating Actionable Information
TechnologyProcess
People –Organization
Governance
People –Culture & Skills
• Enterprise Plan & Staffing
Communication, coordination across efforts criticalSuccess = BEST(A + Q + T), time, resource constrained
The Virtua Toolbox
Leadership decisions
WORK‐OUTEvent driven
Wisdom sharingJust Fix It
Fast action for quick wins
Change Acceleration Process
SIX‐SIGMAReduce defectsReduce variation
Design new process/service(DFSS, DMAIC)
LEANElimination of
waste
Compo
nent of C
hange
Complexity, scope, speed of changeSmall Medium Large
TECHNOLOGYInformation (HW, SW)
Medical + non‐medical equipment
ACu
ltural
Accep
tance
QProcess
Solutio
n
TTechnical
Solutio
n
HEALTHCAREENGINEERING
Systems approach
Optimization
Lean Six Sigma Design for Six SigmaHealthcare Engineering
ProblemI have to eliminate delays and waste from my process. I want to be sure my process is as streamlined as possible.
My process isn’t working. I have inconsistency and variation in my process. I need to eliminate defects to meet my customers
expectations.
This process is so broken we might as well start from scratch and we have new programs we are just starting – I need to build in my customers expectations
I have all this data available on my process but still make
decisions based on anecdotal information, my feelings and
gut instinct
Deliverable
‐ Speed
‐ Efficiency
‐ Productivity
‐ Removing waste
‐Meeting customer expectations
‐ Eliminating defects
‐Meeting customer expectations
‐ Eliminating defects in the design phase of the process
‐Information‐based decision making
‐Benchmarking‐Simulation
Catch phrase“We need to do it better, faster with optimized
resources!”
“We need to fix our process to get it in control so we
consistently meet our customers needs!”
“We need to design this process correctly before we let our customers experience it.”
“We need to turn what data we have into information, and use
this information to make decisions and improve our
process”
Turnaround 40 days 6 – 9 months 6 – 9 months 2 weeks – 4 months
Facilitator Management Engineer & Lean Leader
Black Belt Black BeltManagement Engineer & Lean
Leader
Matching the Tool
Journey to Excellence
Phase I – Getting Started: (2000-2003)Change the Work ValuesBuild ConfidenceTraining
Phase II – Expanding Impact: (2003-2005)Drive Speed and SimplicityImproved Business Results
Cha
nge
Time
Getting Started“Quick Hits”
Gaining Momentum and Acceptance
Hard-wired Into the Organization
Self-sustaining Spontaneity
Phase III – Performance Excellence Culture: (2005-onward)Become the Vision
CAP, Work Out, Six Sigma
DFSS, Lean, Healthcare Engineering
Lean Six Sigma Project Examples:
Home Care Home Health Resource Group (HHRG) Case Weight Mix and CodingResult: Improved documentation and coding practice moving from a 1.21 to 1.36 case mix resulting in hard dollar benefit of $1.2 M
ED Cash CollectionsResult: Improved collection of managed‐care co‐payments prior to leaving the ED resulting in hard dollar benefit $1.1 M
Administrative DenialsResult: Decreased the administrative denials from 11% to 5.3% resulting in hard dollar benefit $1.4 M
Lean Six Sigma Project Examples:
Hospira Medication Library UtilizationResult: Improved the utilization of the MedNet software drug library for IV medication administration went from 14% to 75%
Dysphagia Screening:Result: Improved the current process to achieve effective screening of
ED patients for Dysphagia prior to oral intake from 19.6 % compliance to
87 % which exceeds the external benchmark of 85% (Get With the Guidelines)
Hand Hygiene:Demonstration project with Joint Commission Center for Transforming Healthcare
Result: over 120% improvement with compliance for pilot units
Design For Six Sigma Project Examples:
Hypothermia:Result: Created a standardize enterprise‐wide process to provide moderate therapeutic hypothermia care to appropriately identified patients from the initiation of cooling to therapeutic temperature reached within 18‐60 minutes, 100% compliance
Access Navigation:Result: Designed and implemented access navigation service for patients and their primary care physicians to improve knowledge, access to and knowledge of Virtua services. At end of pilot, 777 patients navigated and 850 appointments made
Care Coordination:Result: Developed care coordination model that resulted in likelihood to recommend from 9% ranking to 75% ranking
Kaizen Impact: Discharge Planning
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Operation Problem Actions taken Results
Patient Discharge Process
•Unclear role definition during discharge•Delays in every step of the process•Long waits to transport patients upon discharge
•Piloted new discharge process on 6 Tele•Created SOP to use same staff member for stripping & logging the bed, and escorting the patient out•Eliminated need for transport staff in discharge process
• 75% Reduction in hand‐offs•Reduction in “discharge to depart” time from ~56 minutes to ~10 minutes
•Patient Satisfaction: ‘wait time in the ED’ improved from mean score of 59 to 84.
Before Kaizen After Kaizen
Kaizen Impact: Medicare Outpatient Billing
Operation Problem Actions taken Results
Processing Claims
•Inconsistency on how claims are processed•Knowledge to fix claim was not easily available and was centered around a person•Inability to monitor claim status within lifecycle
•Created Standard Operating Procedures to handle daily routine tasks•Centralized knowledge database•Generated status flags for each claim as it progresses through the cycle
• Reduced wait time to process a claim an average of 7 days•$267,845 savings•Ability for Management to monitor productivity & health of the business
People Based Process Based
Site Visits Leading
Practice Research
Peer to Peer Surveys
Photo Journaling
Technology Roadmaps
From-to Adjacency
High LevelFlow
ARENASimulation
IT Enablers
Evidence Based Design
Patient Experience
Des
ign
FutureState
Transformation
DesignIntelligence
Mov
e In
SafetyChecklists
New Replacement Hospital: Process Driven Design Approach
Process Driven Facility Design Benefits
Getting it right the first time∼ Minimal change orders; Over $22 M in savings
150+ new process transformation projects∼ Use of Virtua toolbox (six sigma, lean, DFSS, etc) to operationalize and
pilot prior to move‐day
‘Space’ saving of ~280k ft2 in design efforts∼ Conservative cost savings $ 12.1 million
Master Planning & Validation: Simulation∼ Seasonality and changes in care model: Savings of $12M
Process Driven Facility Design Benefits
Right tools, right place & right time: saving up to ~4,260 miles in annual staff movement∼ Today an avg Virtua nurse walks from Philadelphia to Atlanta on an annual basis
∼ More time by bedside
Maximizing ‘Flexibility’∼ Flexible operational spaces & future ‘horizontal expansion zones’
Enhanced ‘Safety & Quality’; with workspaces that enable the effective delivery of care
New Hospital Opening: Sunday, May 22nd
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Driving Sustainability of Results
October 2000 – Present
23 Waves
100+ Six Sigma & DFSS Projects
Results: $28.5 M+ Gross new revenue
Yellow Belts:
Total Trained: 898
Active: 697
Green Belts:
Total Certified: 121
Active: 85
Black Belts:
Total Certified: 22
Active: 17
Master Black Belts:
Total Certified 7
Active: 5
Star Coaches:
Total Certified 377
Active: 246
Questions
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