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Ken Westman, CEO & Ben Power, Quality Coordinator
Rob Brandt, CEO & Kyle Kohn, QI Coordinator
Lean FrameworkEliminate Waste
Eliminate Variability
Eliminate Inflexibility
Rigorous Performance Improvement
Involve Users in
Improvement
Sustain & Continuously Improve
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Ken Westman, CEO
Ben Power, Quality Coordinator
Barrett Hospital & HealthCare
Dillon, MT
Safety vision:
TRUE NORTH=ZERO HARM.
BHH Mission, Vision, and Values Mission: Provide compassionate care, healing, and
health‐improving service to all community members
throughout life's journey
Vision: To be the model in rural healthcare delivery for
the United States in all facets of primary health
services
Values: ICARE (Integrity, Compassion, Adaptability,
Respect and Excellence)
Vision How do we get there?
We must be SAFE…
…For everyone who walks through our doors
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Creating a Culture of Safety
Merriam‐Webster
…to become the safest Critical Access Hospital
Staff Need… To feel safe (physically, professionally and emotionally)
To be willing to report a problem without fear
A safe and easy way to speak up
To know management will take action
To know the problem will be solved
To feel appreciated
“Building” a Culture of Safety
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A Culture of BLAME Asks “Who”
Punishes on severity of outcome
Promotes cover‐ups, quick fixes and poor communication
Pushes problems underground
Leaves safety issues unaddressed
Can lead to tragic outcomes
<a href="http://www.freestock.com/free‐photos/man‐pointing‐isolated‐white‐background‐49068040">Image used under license from Freestock.com</a>
A Just Culture Asks “Why” and “How”
Fosters a culture of reporting and learning
Fosters accountability
Makes outcomes irrelevant
Approaches problems systematically and consistently
Supports and encourages candidness and openness
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Just Culture Training Outcome Engenuity onsite Fall 2012 for Management “Just Culture” Training
Resulted in broad HR policy changes
Continues to move us away from a culture of blame
CEO driven and supported by the Board and senior leadership team (and continues to be)
Lean Healthcare One single way for our entire organization to approach problem solving and process/quality improvement
<a href="http://www.freestock.com/free‐photos/lightbulb‐made‐3d‐white‐background‐2212390">Image used under license from Freestock.com</a>
Education and Training For the Board and Leadership Team
Value Capture engagement
ThedaCare
For staff, management, and leadership
HealthTechS3 Engagement
Management and leadership as “coaches”
CEO driven
Supported by the board and leadership team
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Identified Our “True North”
ZERO Harm
Why Zero Harm?
Why Zero Harm? Because 1 harm event is 1 too many
Because it’s about people (not “rates”)
Zero harm is what we must relentlessly pursue for the ones we love and care for
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“True North” Metrics…
Lean methodology…
Creates a common language for improvement
Researched, evidence based format
Patient‐centric
Improvements identified by those doing the work
“Words may inspire, but only action creates change.”Simon Sinek in Start with Why
Transforming Culture with Lean
Lean Philosophy Creating value by understanding what customers value
Continuous pursuit of the perfect process through waste elimination.
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The Toyota Way I. Continuous Improvement
Form a long term vision and meet challenges with courage and creativity
Always driving for innovation and evolution
Go to the source to find the facts to make correct decisions, build consensus and achieve goals
II. Respect for People
Make every effort to understand each other, take responsibility and do the best to build mutual trust
Stimulate personal and professional growth, share development opportunities, and maximize individual and team performance
Lean: Simple FormulaLiberate the people who do the work to use a proven method to stand back and look at what they do to identify elements of the work that permit:
• Errors and delay in care/service
• Waste of resources
• Frustration in the workplace
Jojo: Slowly, Gradually, Steadily
“There’s no genius in our company. We do what we believe is right, trying every day to improve every bit and piece. Butwhen 70 years of very small improvements accumulate, they become a revolution.”
Katsuaki Watanabe, CEO, Toyota Motor Company
Lessons from Toyota’s Long Driveby: Thomas A. Stewart and Anand P. Raman
July–August 2007 issue of Harvard Business Review
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Weekly Leadership Meeting
Organization‐Wide Goals FY ‘18 SAFETY & QUALITY PILLAR GOAL:
S: Performance Improvement Participation in the creation of at least one Value Stream Map separate from
LEAN classes Completion of at least one A3 including clear problem statement, list of
stakeholders and baseline measure, identification of root cause, implementation and evaluation of solution with follow up measure, plan for standardization or alternate solution
LEAN training of at least two staff (or remainder of staff) OR LEAN training of Manager/Supervisor. If department has met training requirements, completed follow through testing and standardization of previous FYs LEAN project.
Generation of at least one Help Chain Alert (HCA) with identification of root cause, implementation and evaluation of solution, plan for standardization or alternate solution
M: ≥ 90% completion (# tasks completed / # of depts. or groups X 4 tasks per dept or group)
A: Each department is able to identify risk or potential risk, opportunities for improvement and/or reduction of waste; LEAN classes offered in Oct, Jan, and Mar; LEAN instructors will assist with VSM and LEAN projects
R: Safety and quality T: 6/30/2018
Lean Integration From QI View Standardization combined with continuous improvement creates value. Lean is the combination of those things.
One vision for improvement
Requires immense culture change
Two primary areas of integration with our quality program
Help Chain Alerts
Focal Point Goals
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Help Chain Alerts Replaced incident reporting (2012), provides near‐immediate response.
Help Chain Alerts
Help Chain Alerts Follow Up
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Help Chain Alerts Status FY17
Pitocin Near Harm…
Pitocin/Zofran A3
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Results
3.25
1.84
0.43
2014 2015 2016
Fall Related Injuries Per 1000 Pt Days
Results Medication errors dropped by approximately 50% since implementation of Help Chain Alerts
Other factors involved such as implementation of Epic/BCMA/CPOE but those are integrated with the help chain as well
Thus far in FY18, 25% of HCAs standardized compared to 8% in FY17. This is in part due to an improvement being done on the HCA process itself.
Focal Point Annual goal‐setting and project planning/implementation
Each department presents their plan in the fall, then presents their results in the spring.
Requirements change annually as the program develops. This is intentional, to continuously improve the process itself. They do not always get progressively more difficult.
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Focal Point – Lean QI Everywhere
Focal Point Development
FY15 FY16 FY17 FY18
# of projects 2 4 4 1 or more
Methodology Any Any Any Lean
Changes Add projects
Begin to emphasize measurement
Coach DMs to steer tool use towards Lean thinking. Require measurement.
Use of full Lean methodology including VSM and A3. Do 1 additional HCA. Reward multidisciplinary projects.
Focal Point Example
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Shift in Solution Philosophy
Pitfalls of Integration Lack of skilled coaching/not enough coaches
Breaking the Triple Aim apart
Lack of improvement of the improvement process itself
Fixing people through education
Lack of constant, visible senior leadership support
Not putting QI in your employees’ job descriptions
Accepting poor RCAs/problem statements from project leads, or accepting a “non‐preventable” conclusion without first identifying the root cause
Ease the Lean Transition for QI Lead the culture yourself and prepare for a lengthy time frame for uptake. Growth will typically be slow but you will eventually get groundswell.
Expect your QI staff to be experts on the process of process improvement, not the content of the processes they are improving. QI staff are no longer authorities on everything – they’re coaching and measurement specialists.
Find a way to teach basic Lean to all staff and get them involved with a project at least once a year.
Require pre/post measurements for every significant project. Report summary data to the board.
Invest in Lean. Make it strategic. Budget for it as it grows.
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Our Safety and Quality Team
References: Classen, D.C., Resar, R., Griffin, F, et al. “Global Trigger Tool Shows That
Adverse Events in Hospitals May Be Ten Times Greater Than Previously Measured”, Health Affairs, April 2011 vol. 30 no. 4, 581‐589.
CMS.gov “About the Partnership for Patients.” https://partnershipforpatients.cms.gov/about-the-partnership/aboutthepartnershipforpatients.html
Landigran, Christopher P., Parry, G. et al. “Temporal Trends in Rates of Patient harm resulting from Medical Care”, New England Journal of Medicine, November 25, 2010, 363:2124‐2134.
Outcome Engenuity. https://www.outcome‐eng.com/the‐three‐behaviors‐in‐a‐just‐culture‐life‐examples
Outcome Engenuity. Just Culture Algorithm™ v3.2 (from The Just Culture Community, Outcome Engenuity) https://www.outcome‐eng.com
Tremain, Stephen MD, FACPE, Physician Improvement Advisor, Cynosure Health. www.cynosurehealth.org
Value Capture, LLC. One North Shore Center, 12 Federal Street, Suite 100, Pittsburgh, PA 15212. www.valuecapturellc.com
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References Continued:
MountainviewMedical Center
White Sulphur Springs
Effective problem solving on a organization wide scale:
A high level look at Mountainview’s approach to quality and revenue cycle success
Rob Brandt ‐ CEO
Kyle Kohn ‐ Process Coordinator
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Facilitating quality from top down
Staff buy‐in on quality
Success creates trust
Staff specifically tasked with problem solving/improvement
Utilize methodology that systematically steps from a
problem to a solution
Break a monumental project into bite‐size improvements
Evolution of problem solving
What is the process? (scope)
Who’s involved with the process? (stakeholders)
Get the staff doing the processes involved
Revenue cycle team
What’s the current status of the project?
Without making changes as you assess, what does the process look like now?
A problem exists – what now?
MMC rev‐cycle: Current state
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0 20 40 60 80 100 120
coverage guidelines not met
info requested from patient
missing/incomplete/invalid procedure code
non covered charge
precert/authorization missing
procedure not paid seperately
procedure/treatment/drug experimental
lacks info or has submission/billing errors
missing/incomplete/invalid HCPCS
missing documentation
procedure code incedental to another procedure
program guidelines not met
procedure code inconsistent with modifer
ineligible for service
misrouted claim
previously paid
not covered during same session/date
payment included in other service
noncovered charge
patient couldn’t be identified
charges previously considered
missing/invalid bill type
provider type may not bill for this
claim lacks info
not our patient
care may be covered by another payer
missing/incomplete/invalid HCPS modifer
NDC
Invalid procedure code
authorization # missing
duplicate
Combined denials 2/1 ‐ 5/1 (364 total denials)
Use data to influence need for change
Target the most common/costly breakdowns first (Pareto technique)
Use data to monitor effects of change
Did the change do what we wanted/expected?
Did the change have unanticipated consequences?
What are we fixing? Did it work?
Improvement should be measurable not emotional
Revenue cycle focus already had a significant measurable impact:
55.8% reduction in denials from baseline in first 3 months
6.8 Weeks of a Full‐Time employee’s time
Defining a metric to gauge improvement
“Process is x amount better or worse”vs.
“it seems better or worse”
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accident info
prev processed
not compensable
deny billed provider type
submission/billing error
info request from patient
accident info
no prior auth on file
ineligible for service
prog procedure code
managed care
medicare part A only
claim lacks info
other part liable
invalid procedure code
non‐covered service
not deemed medically necessity
duplicate claim
missing/invalid NDC #
not covered on date
auth # missing or invalid
Claim denials May ‐ July 2017 (161 total denials)
After implementation, work is far from over
Always working towards best possible method Better tomorrow than today
Improvement part of every‐day work
Continuous improvement
identifies problem(s) at hand
gives direction on large scale projects bite size improvements
addresses problem(s) with appropriate countermeasures
measures effect of change
continually refines process ‐ best possible method continuous improvement
Sound problem solving methodology:
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Thank you for your time!
Any Questions?