Improving Home Care Financials with Lean Six Sigma

Rebecca Kjonegaard, MSN, RN, CICLean Six Sigma Black Belt

Integrated Delivery System

79,674 annual discharges

2,060 licensed beds

14,749 employees

2,600 physicians

2,764 volunteers

$2.1 billion in annual revenues

• Problem Statement

– In 2008, 474 patients were outsourced

– Lost net revenue over $1.2 million annually

• Goal

– Improve efficiencies in intake and scheduling process

– Increase number of patients admitted to service

– Decrease number of patients outsourced narrowing the gap by 50%

– Improve Home Health operational performance by $627,000

Define

Key Project Metrics• Outsourced

– 69,237 DPMO– 2.9 sigma– 7% of our business is outsourced– Goal: Reduce by 50%

• Not seen within 48 hours– 194,594 DPMO– 2.3 sigma– 19.5% non-compliant– Goal: Reduce by 50%

MeasureIntake-Scheduling Process

Current State

Excessive delay due to clerk placing worksheet in bin and intake staff selectively working referrals

Overall time 42 hrs

18% of our patients are not seen within the 48 hour state requirement

Measure48 hour Target

02468

101214161820

48 hour

Per

cent

of C

ases

Exc

eedi

ng 4

8 ho

ur

18% (23/130)

Good

Analyze

Delay in Intake –Scheduling process

Scheduling

Workflow

Referrals

Fax not taken off of Fax immediately

Inappropriate referral

Incomplete referrals

Too many different forms/worksheets that intake/liaison has to fill out, etc.

Nurse does not have the skills so cannot see patient

Not syncing timely, schedules not showing up

Schedules not entered, not current

Too many different computer program sources that intake/liaison has to look through

Not getting back to a patient I’ve seen before, someone else is starting from scratch

Not enough staff later in the week

21% of referrals are not admitted which are determined at the end of the intake process – accounts for 14% hours spent on non-admitted cases

AnalyzeNot Admitted During Intake in the

Office March 2009

0

5

10

15

20

25

Not Admitted During Intake Process

perc

ent n

ot a

dmitt

ed

21% (27/130)

Good

Analyze

5% not admitted when the clinician visits the patient to admit for Home Health services – accounts for 5.6% hours spent on non-

admitted cases

Not Admitted in the FieldMarch 2009

0

1

2

3

4

5

6

Not Admitted in Field

Per

cent

Not

Adm

itted

5% (7/130)

Good

The Home Health Intake Department receive the highest number of referrals on Wednesday

Day of Week Referral Received in March 2009

0

5

10

15

20

25

30

35

40

Sun Mon Tue Wed Thur Fri Sat

Day of Week

Num

ber

of r

efer

rals

Analyze

Schedule of Nurse and PT March 2009

More staff scheduled at beginning of week inconsistent with referrals and patients being admitted

Analyze

Both Nursing and Physical Therapist have low compliance with syncing twice a day

Percent Sync in February 2009

0%

10%

20%

30%

40%

50%

60%

Nurse and PT

Per

cent

Syn

c%Nurse sync

%PTsync

39%(104/265)

49% (237/484)

Good

Analyze

ImproveNew Intake -Scheduling Process

Most significant decrease is between receiving the referral and the initiation of worksheet (from 17.2 to 6.7 hours)

Forms,documentation

Scheduling improved, skills and competencies addressed,work expectation clarified

Scripting

Overall time 29 hr

Total Time for Intake Process

Comparing the baseline and remeasure the Mann-Whitney Test indicated statistical significance with a p value .0033

Baseline

March 2009Remeasure

April 2009

Improve

Not statistically significant between March and April

Comparing March and June the Two Proportions test indicated statistical significance with a p value <0.05

48 hour TargetMarch, April, June

0

5

10

15

20

25

30

March April June

Month

Pec

ent o

utsi

de o

f 48

hour

18% (23/130)

24% (13/55)

6%

( 4/65)

Good

Improve

Not statistically significant between March and AprilNot statistically significant between March and June

but trending in the right direction

Not Admitted To Service During IntakeMarch, April, June 2009

0

5

10

15

20

25

30

March April June

Month

Per

cent

not

adm

itted

21%

(27/130)22%

(12/55)23%

(15/65)

Good

Improve

Not statistically significant between March and AprilNot statistically significant between March and June

but trending in the right direction

Not Admit in the FieldMarch, April, June 2009

0

5

10

15

20

25

30

March April June

Month

Per

cent

not

adm

it

5% (7/130)

9%

(5/55) 3%(2/65)

Good

Improve

Sponsor Improves

• Staffing patterns• Staff skills and competency• Education for referring agencies

In March the most referrals received on WednesdayIn June the most referrals received on Thursday

Both are inconsistent with staff schedule

Week Day Referral Received March and June 2009

0

10

20

30

40

50

Mon Tue Wed Thu Fri Sat Sun

Day of the week

Num

ber

of r

efer

rals

March

June

Referrals Received

In both March and June most admissions on Thursday which is inconsistent with staff schedule

Day of Week AdmissionsMarch and June 2009

0

10

20

30

40

50

Mon Tue Wed Thu Fri Sat Sun

Day of Week

Num

ber

of A

dmis

sion

s

March

June

Patient Admissions

Schedule of Nurse and PTRN & PT Schedule for June 09

0

20

40

60

80

100

120

140

160

180

200

Mon Tue Wed Thu Fri Sat Sun

Num

ber

of R

N a

nd P

T

RN

PT

More staff scheduled in beginning of week which is inconsistent with referrals and admissions

Continued low compliance by Nurses and Physical Therapists with syncing twice a day resulting in schedule conflicts

Synchronization Feb and June 2009

0

10

20

30

40

50

60

70

80

90

100

Nursing PT

Per

cent

Syn

c

Feb

June

49%

(237/484)40%

(204/517)

39%

(104/265)39%

(100/255)

Good

Field Staff Synchronization

Key Project Metrics

Outsourced:Baseline (CY 2008) Remeasure (Apr – Jun 2009)• 69,237 DPMO • 32,088 DPMO• 2.9 Sigma • 3.3 Sigma• 7% business outsourced • 3.2% business outsourced

Benefit: $677,672 increase in revenue (annualized)

Not seen within 48 hours:Baseline (Mar 2009) Remeasure (Jun 2009)• 194,594 DPMO • 62,500 DPMO • 2.3 sigma • 3.1 sigma• 19.5% non-compliant • 6% non-compliant

Benefit: Increased compliance with regulation

Key Project Metrics

Field staff synchronization:Baseline (Feb 2009) Remeasure (Jun 2009)• 544,726 DPMO • 606,218 DPMO• 1.3 Sigma • 1.2 Sigma• 45.5% synching • 39% synching

Takeaway: More effort focused on understanding root c ause of problem and developing solutions to change behavior

Lessons Learned• Progress made – not so easy

• Identified resistance in key stakeholders• Staff lack of knowledge on Six Sigma

methodology slowed the progress• Addition of new team member changed

group dynamic

• Large team difficult to manage• Limited champion involvement impacts

overall follow through

Questions & Discussion