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Lean Six Sigma White Belt Certification

ProgramOwen J. Dahl, MBA, FACHE, CHBC,LSSMBB

MGMA

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Objectives

To define Lean and Six Sigma

To identify key tools used in implementing LSS in your practice

To provide practical ideas and applications for LSS

To challenge you to transform your practice in areas of efficiency, quality, and cost effectiveness

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Standardize = create valueManage for the exception

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History and Background

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History of Six Sigma

• 18th Century – Carl Frederick Gauss = normal curve

• 1920’s – Shewhart, standardize product variation, 3 Sigma

• 1980 – Motorola – methodology and culture change• Documented savings of $16B• Focus on customer

• More than TQM and ISO

• Seen then as• Vision, philosophy, symbol, metric, goal, and methodology

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History of Lean

• Henry Ford = 1913 - standard work and moving conveyance to create work flow• Big issue, couldn’t provide variety

• Toyoda – 1930 – simple innovations could provide process flow and meet needs for variation

• Lean Thinking, 1996 (Womack and Jones) – Five principles• Value desired by the customer• Value stream for each product (service)• Product (service) flow continuously• “Pull” between steps• Manage toward perfection

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Basics of Lean

• Definition

“…Practice that considers the expenditure of resources for any goal other than the creation of value for the end customer to be wasteful and thus a target for elimination. In a more basic term, more value withless work.”

Waste, variation, and lag = loss in value

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Source: Wikipedia, 2010

What is Lean?

Lean is all about reducing waste

• Reduce the time it takes to deliver a service and increase efficiency without sacrificing quality

• Shorten the time between when you see the patient and you get the cash

Lean looks at the value stream of any process with the goal to eliminate steps that do not provide

• Value to the organization, or• Value to the customer

Lean is more applicable to medical practices

• Shorter improvement cycle• Less expensive delivery system• Fewer resources

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Principles of Lean

• Value –• as defined by the customer & delivered by the producer

• Value Stream –• identify set of actions required to bring the product or service to the

customer

• Flow –• smooth movement

• Pull –• the downstream customer triggers the need

• Perfection –• no defects

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What is Six Sigma

• An improvement model designed to reduce the variability that exists within any given process• Eliminate errors and mistakes

• Six Sigma is a metric measured in unacceptable events per million• 6 σ = 3.4 per million• 5 σ = 233 per million• 4 σ = 6,210 per million• 3 σ = 66,810 per million

• Sigma measures variation rather than averages

• Six Sigma is counter-intuitive in that the process is within control up to a variation of six standard deviations

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What is Lean Six Sigma?

Lean Six Sigma combines the strengths of each system into one

• Lean • Guiding principles based

operating system

• Relentless elimination of all waste

• Creation of process flow and demand pull

• Resource optimization

• Simple and visual

• Efficiency

• Six Sigma• Focus on voice of the

customer• Data and fact based decision

making• Variation reduction to near

perfection levels • Analytical and statistical

rigor

• Effectiveness11

Continuous Process Improvement

• Continuous Process Improvement, CPI, is a program of activities designed to improve the performance and maturity of an organization’s process with regard to a set of goals

• The key to successful CPI –

• Finding the best approach to meet the business goals of the organization

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CPI Begins with Benchmarking

Current state or condition of operational components

PMS and other IT systems

Find and review MCO contracts

Accounting system and financial performance benchmarks

Patient Capacity (Maximum, minimum, excess, over, etc.)

Cycle Time

HR policies and practices

Value stream efficiencies

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Primary CPI Metrics

Profit and profitability

Capacity

Cycle times

Contract effectiveness

Performance and productivity

Utilization

Resources

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Voice of the Customer

• Process used to obtain feedback/requirements from the customer to provide them with the best service quality possible

• Proactive

• Captured through• Interviews• Surveys• Focus groups• Observations• Complaint logs

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Meet customer expectations

• Service MUST meet customer expectation requirements

• Must understand the customer expectation

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V = R - EV = Value (Quality)R = ResultsE - Expectations

Patient Satisfaction Survey

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Process Focus (Ongoing)

• Why have a process focus?

• So we can understand how and why work gets done

• To characterize patient/physician/payer relationships

• To manage for maximum patient/payer/staff satisfaction while utilizing minimum resources

• To see the process from start to finish as it is currentlybeing performed

• Blame the process, not the people

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Process – a repetitive and systematic series of steps or activitieswhere inputs are modified to achieve a value added output

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Basics of Lean

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Input

Outcome(Not just the

process; is the patient

satisfied?)

PhysVisitEnter

Room-ing Exit

Post-visit

action

4 6 12 3 8 33 Minutes cumulative time

Each step has aseries of tasksand takes a certain amountof time!

Patient roomed

Patient arrives

Physician performs

assessment and plan

Post-visit work

performed

What are the “Gaps” in between?

Waste (Downtime) (muda)

• Defects

• Overproduction

• Waiting

• Not using Talent

• Transport

• Inventory

• Motion

• Extra processing

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DIRFT

Eight Elements of Process Improvement

1. Recognize the current state of the practice

2. Define what plans must be in place to improve each state

3. Measure the systems that support the plans

4. Analyze gaps (variance) in system performance benchmarks

5. Improve system elements to achieve benchmarks

6. Control system-level characteristics critical to improvement

7. Standardize the systems that prove to be best in class

8. Integrate these systems into the business framework

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What is a project? (Beginning & End)

Any temporary, organized effort that creates a unique product, service, process or plan

Projects bring together people from a wide range of jobs and provides them with the opportunity to collaborate in a unique way

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Project Oriented Organizations

• Recognize that customers are important

• Realize that speed, quality and cost are universally linked

• Believe that variation must be minimized

• Know that bottlenecks need to be identified and removed

• Use data and metrics as a key to decision making

• Understand the importance of teams

• Recognize that every employee, in one way or another, needs to be engaged in the process improvement strategy

• Turn to outside assistance, when necessary, to keep from stagnating

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Project plan

• Document used to guide both project execution and project control

• Project Charter

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Culture defined . . .

• Culture in its broadest sense is cultivated behavior; that is the totality of a person's learned, accumulated experience which is socially transmitted, or more briefly, behavior through social learning.

• A culture is a way of life of a group of people--the behaviors, beliefs, values, and symbols that they accept, generally without thinking about them, and that are passed along by communication and imitation from one generation to the next.

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Source: https://www.tamu.edu/faculty/choudhury/culture.html

Culture – 6 components

• Built on the vision – mission of the practice

• Built on the values

• Built on the “practices”

• Built on the people

• Built on the language used

• Built on the place

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Source: http://blogs.hbr.org/2013/05/six-components-of-culture/

Deployment PlatformsDefine – Measure – Analyze – Improve – Control

Plan – Do – Study – Act

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DMAIC

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Document, communicate and check for replication and sustainability

Long-term implementation

Verify results

Develop action plans, implement improvements

Develop solutions

Determine cause

Define condition

Identify problems

Define the Process

Determine to whom the process is focused

Who are the customers?• Patients• Payers• Staff

List the customers’ requirements• Quality• Speed• Value

Define the process boundaries• Map the first and last steps first

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Measure - Collect the Data

Know ahead of time what data you need vs. what data you can collect

For primary research, create a design for the experiment

• This is particularly prevalent with cycle time studies

Look for existing studies

Identify specialists within (and outside of) your organization that may be necessary to assist you

• IT support• PMS support

Have a written data collection plan

• Includes the ‘what’ and ‘where’ and ‘who’30

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Analyze the Data

Separate useful from fun-to-know data

Use analytical tools and statistical methods to conduct the analysis

Look for variability and conduct root-cause analyses to understand the underlying conditions

The key is accountability

• Someone within the organization should be able to explain, in understandable language, the reason for every significant variation.

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What is in the Data Box?

Who does it?

How many people does it take?

Cycle time for the task

Average daily requirement (Daily Demand Rate)

Delay time prior to the task

Process step details

Average delay before this step occurs

Total units waiting (claims, patients, charts, etc.)

Top 3 rework issues

Top 3 risks

Artifacts (screen captures, forms, traceable documents, etc.)

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Improve the Process

Use the information from the VSM and analysis phase to recommend process improvements

Develop future state maps with the improvements embedded and compare to current state maps

Include contingencies associated to risk analysis

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Control the Process

Determine when to review

Identify what should be reviewed

Consider doing it again

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PDS(C)A – a “lean” deployment platform

• Plan

• Do

• Study (Check)

• Act

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Plan

• Purpose of the test?

• What change idea are you trying?

• Indicators of success?

• How will data be collected?

• How many subjects tested?

• What is the time frame?

• What do we hypothesize will happen?

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Do

• Conduct the test

• Document any problems with unintended consequences

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Study (Check)

• Analyze the data

• Study the results

• Compare the data to your predictions

• Summarize and reflect on what was learned

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Act

• Refine the change, based on lessons learned from the test

• Prepare a Plan for the next PDSA cycle

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PDSA is not a Full Blown Plan!

• PDSAs are small in scale

• So if you are … • Thinking months – think weeks; thinking weeks – think days;

thinking days – think hours

• Thinking facility – think unit; thinking unit – think teams; thinking teams - think ONE team

• Thinking all patients – think a type of patient; thinking a type of patient - think a sample; thinking sample - then 3-5 may be enough

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Tools in the Tool Box

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What is Process Mapping

A process map, or flow chart, is: Visual representation of a process that can illustrate:

• What activities are completed, by whom, in what sequence• Hand-offs between departments or individuals• Internal and external operational boundaries (swim lanes)

Why map a process? Diagnosis and Improvement • Determine the cause of a problem or condition Provide a critical assessment of what really happens within an institution Training and Communication

• Serve as component of training or operations manual.

Process mapping can be constructed both informally and formally Informal method is best for getting started and securing buy-in Formal method ensures rigor and accuracy

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Basic Procedure• Define the process to be diagrammed.

• Discuss and decide on the boundaries of your process: Where or when does the process start? Where or when does it end? Discuss and decide on the level of detail to be included in the diagram.

• Brainstorm the activities that take place. Write each on a card or sticky note. Sequence is not important at this point, although thinking in sequence may help people remember all the steps.

• Arrange the activities in proper sequence.

• When all activities are included and everyone agrees that the sequence is correct, draw arrows to show the flow of the process.

• Review the flowchart with others involved in the process (workers, supervisors, suppliers, customers) to see if they agree that the process is drawn accurately.

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Materials needed: sticky notes or cards, flipchart, marking pens

Process Mapping Symbols

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Standardized symbols enable the map to clearly, visually display what happens in a given process. The most common symbols include:

However…

Keep the overall number of different symbols in a map as limited as possible to prevent confusion

Avoid being hampered by nomenclature. Choose what works best for your institution.

= Processing step or task

= Decision point or checkpoint

= Queue or wait point

= Form or documentation

= Information sent to MIS

= Start or stop point

Don’t need high tech approach

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Oval = start

Rectangle = process

Diamond = Decision

Document

ProcessMap

Basic Revenue

Cycle

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Denial management

• Take the knowledge regarding denials – and fix the problem where it originated• Front office/registration • Pre-authorization

• Review charges prior to release• Automated review via claims scrubber• Manual review

• Check-out staff• Insurance follow-up staff

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Most common!!

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Denial management

• Other ideas?• Hire staff who know how to identify a denial

• Implement a protocol to systematically record at the line item (CPT®) level, ideally by cause

• Develop a list of payer appeal time frames

• Write an appeal letter, keep in template form so that it can be easily adopted to new appeal

• Utilize appeal software tools

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http://www.physicianspractice.com/pearls/five-tips-better-manage-your-revenue-cycle

Hiring –staff

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What is your turnover rate?

Do you have the right numberof employees?

In the right positions?

Map Inspection Points

• The purpose of the inspection points is to identify potential errors before they reach the customer• Patient• Payer• Staff

• For each step, ask yourself, “what could go wrong?”• Errors• Duplication• Waste• Risk

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What is Value Stream Mapping?

Value stream mapping starts as a paper and pencil tool that helps you to see and understand the flow of objects, patients, materials, supplies and information as a product or service makes its way through the value stream.

It differs from the process mapping in four ways: It gathers and displays a far broader range of information than a typical process

map It tends to be more specific than process maps It tends to be used at a broader level, i.e. from inventory to accounting to clinical It tends to be used to identify where to focus future projects, subprojects, and/or

kaizen events A value stream map takes into account not only the activity of the

procedure/service, but the management and information systems that support the basic process. This is especially helpful when working to reduce cycle time, because you gain

insight into the decision making flow in addition to the process flow The basic idea is to first map your process, then map the information flow

that enables the process to occur

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VSM - examples4

minutes

6minutes

14minutes

13minutes

7minutes

44minutes

4minutes

3 Minutes

8Minutes

32minutes

47minutes

91Minutes

What is value added?

What is business value added?

What is non-value added?

What is the process cycle efficiency?(48.3%)

Identify wastes by type:

•••••

VSM Challenges in a Medical Practice

• Speed of change is usually slower

• Policies are well established and politics get in the way

• It is often difficult to establish the metrics needed to measure and analyze processes and results

• Even though it is easy to see what needs fixing, it normally takes longer to achieve results

• Establishing the true cost of quality and the cost of the process is much more difficult than other industries

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Takt Time

• Time available

• Services performed

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Eight hour day 48025 patients to be seenMinutes per patient 19.2

30 minute break ‐30Time Available 450No break 18.0

Six hour day 360Minutes per patient 14.4

Includes:Prep

In RoomDocumentation

Run Chart

0

20

40

60

80

100

120

140

160

180

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41

Run Chart

Visits

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Actual Practice Control Chart

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-

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

1 2 3 4 5 6 7 8 9 101112131415161718192021

Dr. TM

Upper

Actual

Average

Lower

-

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Dr. JT

Upper

Actual

Average

Lower

-

20.00

40.00

60.00

80.00

100.00

120.00

1 3 5 7 9 11 13 15 17 19 21

Dr. WW

Series1

Series2

Series3

Series4

In 10%  Total % In

Dr BY 3 11 27.3%

Dr PB 3 16 18.8%

Dr NM 3 9 33.3%

Dr TM 8 21 38.1%

Dr JT 5 19 26.3%

Dr WW 5 22 22.7%

Group 27 98 27.6%

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Control chart

• Measurement• Center line = average

• Upper and lower control limits = 3 sigma

• Those involved when seeing results should know• Special cause

• Why or what happened

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Run vs. control chart

• Run – single line that displays observed data in a time sequence, shows trends, exceptions, shifts or patterns

• Control – based on a run chart but adds upper and lower control limits with a “centerline”. Addresses the question: is my process stable or in control

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What’s Wrong with my Practice?

• A practice analysis is a business adaptation of differential diagnoses

• A general assessment is akin to a physical exam

• Granularity as it relates to the operational, financial and efficiency of the medical practice requires the same diagnostic events that a physician requires when drilling down on a diagnoses• Capacity• A/R• Cycle times• Denial analysis• etc

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Cause and Effect

The linking together of events

• Does an event cause a change? • Is there a threshold of causation?• Why did it happen?• If I remove one problem, does it create another?

Establishing causation is more difficult than correlation and often requires qualitative tools

• Change in payer mix equals change in revenue?• Length of time to appointment effects rate of no-shows?• Coding training for docs decreases risk of non-compliance?• Quicker phone response increases patient satisfaction?• EMR results in increased revenue and/or decreased A/R?

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What is an Ishikawa Diagram?

• Also called a Fishbone diagram

• This is a tool that is used to drill down during cause-and-effect steps in a project

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What’s Your Problem?

Practice Process

Payers Patients

Ishikawa Diagram

• “Fishbone” or Cause and Effect

• A causal diagram that show the causes of a specific event

• Each cause is the source of a process variation

• Causes are best tracked in major categories

• Major categories: method, materials, methods, and manpower. There are many independent variations and additions.

• You will need to determine the major categories when designing

• Best developed by brainstorming and the “5 whys”

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Ishikawa categories

• Method – staff trained, instructions clear, process changed, design changed, steps listed as “if necessary” or “approximately”

• Material –supplies, inventory, information, MSDS, substitution

• Machine – correct one, maintained, software, hardware, right application for job

• Manpower – experience, skill, on the job training, communication, judgment, fatigue

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Steps to Developing the Ishikawa Diagram

1. Agree on a problem statement (effect), write it at the center right of the flipchart or whiteboard, draw a box around it and draw a horizontal arrow running to it

2. Brainstorm , the major categories of causes of the problem. If this is difficult use generic headings:

a. Policies b. Payers c. People (manpower) d. Equipmente. Measurement f. Environment

3. Write the categories of causes as branches from the main arrow

4. Identify all the possible causes of the problema. Use brainstorming techniques

5. Write sub-causes branching off the causes until all ‘why’s’ have been exhausted

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C & E example

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MachineManpower

Method Materials

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Long Wait

Time for New

Patients

Practice Process

Payers Patients

Patient late (early!)

Unnecessary forms

Scheduling

Insurance Validation

Time of Visit

Pre-authorization

Example – Long Wait Time for New Patients

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Scheduling (mura –unevenness)

• Single interval• One time period per slot: 10, 20, etc. minutes

• Multiple interval• 10 for acute; 20 for new, etc.

• No “right” way to schedule

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Appointment Slot

Average Time to See a Patient

Scheduling• Wave (block) scheduling

• 9 a.m.; 1 p.m.• Not recommended

• Modified wave scheduling• Schedule in “small” waves throughout the day

• 50% at top of hour• 30% 20 minutes after• 20% 30 minutes after

• Recommended for patient population with limited compliance

• Affinity visits

• Group visits69

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Scheduling – Access Indicators

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Time to Next Available New or established Patient Appointment

No-Show Rate

New Patient Appointments as a Percent of Total Appointments

Surgery/Procedure Yield

Cancellation Conversion Rate

Final Steps for the Ishikawa Diagram

• Make sure all possible suggestions have been exhausted• In a team setting, everyone has passed

• Review each of the suggestions and begin a high-level vetting process to remove those that may not be valid• For those that need additional information, assign team

members to investigate and report back

• When whittled down to the ‘real’ causes, begin a process of prioritization for testing and improvement

• Focus on and address those that are the most likely candidates for improvement projects

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5 Why’s

• Why – multiple times = problem solving tool, uncover the root cause

• Problem = Child Got a “D” in math• Why did you get a “D” in math?

• Because I didn’t do all my homework assignments• Why didn’t you do your home work?

• I hate math• Why do you hate math so much?

• Because I suck at it• Why do you think you suck at it?

• I just don’t get it

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5 Why’s

• May not take “5’ to get to the root cause

• This is a guideline, not an absolute

• Drilling down in a vertical fashion, not a horizontal

• Skill developed in asking the right questions

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5 Why’s for a receptionist• Baseline – develop job description and engaged staff

• Question: what do you get paid to do?

• Answer: Greet patients

• 5 Why’s• Why is greeting patients important?

• I was told that was the main part of my job• Why were you told to do that?

• It helps the clinic staff know that the patient is here• Why does the clinic staff need to know the patient is here?

• So they can get the patient into the room• Why is it important to get the patient into the room?

• So they can see the provider• Why does the patient need to see the provider?

• So they can get well, get good patient care

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5 S Methodology• Sort

• Eliminate unnecessary items, RED TAG/FLAG

• Straighten• What do I need to do my job?• Where should I locate this item?• How many of this item do I need?

• Shine• Clean area, work space

• Standardize• Involve staff, best practices• Benchmark

• Sustain• Keep changes in place

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Workflow Optimization

• “Pull in” the work• Avoid interruptions

• Be organized

• Establish protocols for message taking and callbacks• Urgent?

• Referring physician?

• Document in exam room• Customize template

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Time Study

• Direct and continuous observation of a task, recording the time it takes to accomplish• Fredrick Winslow Taylor – late 1800’s early 1900’s

• Used to set standards for task

• Planning for work effort

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Motion Study

• Reviewing and tracking how work is done, the “motions” required to do the work

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Purpose

• General• Eliminate unnecessary motions• Identify the best sequence of motions for maximum

efficiency and productivity• Standardization

• Organization• Performance evaluations• Predict the level of output that may be achieved• Used to uncover problems and create solutions• Used for time cost analysis

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Calculate Standard Time

• Normal time = 10.25minutes

• PFD = .20 - percentage

• Standard time = 12.3 minutes

• PFD =• Personal – rest room, phone call, water• Fatigue – physical, mental, environmental (light, heat)• Delay – clean up, supplies, malfunction, random events

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Steps for Time Study

• Define what is to be studied

• Identify tasks done in the study

• Measure the time (stop watch, log, computer)

• Evaluate the worker’s performance, “performance rate”

• Consider exceptions, factors needed to accomplish the task and compute a standard time

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Normal time for TriageTask Time

(minutes)Rating factor Normal time

Weight 1 1.0 1.0

Temperature 1 1.0 1.0

BloodPressure/pulse

1.5 1.15 1.65

Interview 3 1.40 4.2

Escort to exam room

2 1.20 2.4

Normal time 8.5 10.25

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Problems with time study

• Observers not competent

• Proficiency of those doing the study

• Actions of one, not representative of whole

• Team members may not cooperate• Resent the fact they are being “studied”• Change rate of work while observed• Pressure may increase mistakes• May alter normal methods to affect the study

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Kaizen Event

• Five day, concentrated effort• Day 1 – Current state documentation

• Value stream• Voice of customer

• Day 2 – Current state evaluation• Cause and effect diagram• Brainstorm

• Day 3 – Characterize future state: plan implementation• Project plan

• Day 4 – Implement future state• Use 5S

• Day 5 – Operationalize future state and debrief• Document and review

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Team

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Benefits of being on a Team

Gain a better understanding of the issues

Opportunity to be creative and share ideas

Building stronger working relationships

Learn new skills and enhance existing ones

Work on projects that have support of upper management

Being part of the solution

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Importance of Teams

Most of the time we work with people in teams

Teams can solve more complex problems

Teams are more creative

Teams give us immediate access to multiple skill sets

Teams are always changing

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Team Objectives

The primary purpose of a team is to provide the organization with an efficient and effective model of process improvement and problem resolution

A properly functioning team will:

• Improve employee morale• Develop creative skills of members• Improve relationships and communication• Build problem solving skills and techniques• Demonstrate to management that employees have good ideas

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Type of Teams

Self-directed teams• Operate with little to no day-to-day involvement from

management• Leadership is self-selected and rotates over time• Team leaders have equal responsibility as members• These types of teams are given objectives by management and

expected to meet goals within a given time frame

Cross functional teams• Made up of members who represent different departments• Each member should be a subject-matter expert• Projects are usually major and long-term

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Team Member Selection

Who selects the team?

What is the purpose of the project?• Single issues may only require small, focused team• Multi-issue may require process owners and management• Complex project may require cross-disciplinary members

Always include process owners

Each member needs to contribute in some fashion• Skills, technology, experience, facilitation, etc.

Each team member needs to share the goal

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Team Size

Improvement teams: 8 to 10 from a single department

Quality teams: 5 to 10 from a single department

Cross functional: 5 to 10 from different areas/departments

Self-directed: 6 to 15 from a general work area (+ support)

Teams should not be less than 3 or greater than 20

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Team Roles

Champions

Facilitator

Team leader

Process owners

Inside subject experts

Outside subject experts

The recorder

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Team Champions

• Upper level managers that control and allocate resources

• Team champions should be trained in process improvement techniques and strategies

• Team champions are (should be) there to lend support and encouragement from the organizations upper management• Sometimes, they are just spies and may jeopardize the

benefit of group dynamics

• They are normally involved in all reviews pertaining to project milestones

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Team Facilitator

• Perhaps the most important member of the team because . . . they are not really members

• The facilitator is normally someone from outside the team structure• From a different department• Outside the company (consultant)

• Should be trained in team structure and group dynamics• Forming, storming, norming and performing

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Facilitator Do’s

1. Identify members that need training or skill building

2. Provide feedback on the groups effectiveness

3. Offer an outside perspective

4. Help with defining and summarizing points

5. Keep the team on track (avoiding drift)

6. Assess personality and cultural conflicts

7. Help the leader to be effective

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Facilitator Don’ts

• Being judgmental of ideas and opinions

• Taking sides or getting involved in the issues

• Dominating the discussions (more listening, less talking)

• Recommending solutions or answering questions

• Losing focus or drifting the team

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The Team Leader

• Can be the facilitator, also, but not near as effective

• The team leader should:• Provide direction and suggest assignments• Act as a liaison to management• Handle administrative duties, i.e., meeting site and

scheduling• Enforce meeting rules and regulations (sergeant at

arms)• Work with and not over (or against) members

• The leader should be more of an encourager than a boss

• The role of the team leader will diminish as the team becomes more self-directed

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The Process Owner

• A process owner is someone who is an expert regarding the process being reviewed and/or studied

• The process owner should:• Know the process inside and out• Be able to assist with process and value stream mapping• Have a good understanding of process improvement

techniques• Support team’s missions and goals

• Process owners may or may not be in management positions• billing manager vs. biller• office manager vs. front office staff

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Subject Matter Experts --SME

• Different from the process owners, these are people who offer an expertise in a particular technical area• IT, data analysis, statistics, clinical, CPC, technology, etc.

• Subject experts can be internal, external or both• External experts can provide new and unique perspectives

• Be careful regarding their ability to communicate effectively and work within a group environment• The ‘geek’ factor

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Work Force

• Matures/traditionalists - Born prior to 1945 (75M)

• Baby boomers - Born 1945 - 1964 (80M)• grew up in era of unparalleled upward mobility

• Gen Xers - Born 1964 - 1980 (46M)• grew up with falling wages, shrinking benefits, and growing

economic inequality• by 2010, employees 25 - 44 will decrease by 15%

• Gen Yers (Millennial/Echo Boom/Baby busters)-Born 1981 – 1999 (76M)

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Team Stages• Most teams go through four development stages before

they are able to be considered effective

• As members are added and/or removed from a team, they may go through these stages again, as follows:

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Storming

Norming

Performing

Forming

Performance

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Stage 1 – Forming

• Behaviors• Lack of task focus• Difficulty in defining problem• Uneven participation• Ineffective decision making• Resistance to team building

• Feelings• Excitement, anticipation and

pride• Shaky alliance to the team• Suspicion, fear and anxiety• Roles and responsibilities are

unclear

• How to Improve• Take enough time to get

comfortable with each other• Focus on missions and goals• Establish (and enforce)

ground rules• Follow a structured approach• Train all team members on

team and meeting concepts• Encourage (and even force)

equal participation

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Stage 2 – Storming

• Behaviors• Problem solving is superficial

• Petty disagreements

• Hidden agendas and cliques

• Reaching decisions are like pulling teeth

• Feelings• Resistance is plainly evident

• Individual attitudes and goals vary widely

• Prevalence of petty anger and petty jealousy

• How to Improve• Follow a formal problem-

solving format

• Work on understanding roles

• Deal openly with conflict

• Work to expose hidden agendas

• Get (and keep) the team focused on goals (avoid drift)

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Stage 3 – Norming

• Behaviors• Attitudes improve• Trust and commitment grow• Some goals and objectives are

achieved• Conflicts are resolved• Leadership is shared and

respected

• Feelings• Comfortable with feedback• Sense of cohesion and

purpose• Friendships begin to form

• How to Improve• Evaluation team performance

openly and with discussion• Periodically present summary

of progress• Create ties and relationships

outside the team

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Stage 4 – Performing

• Behaviors• Members work through their

own problems

• Members manage the group process

• Creativity and informality

• Closer bonds are formed

• Feelings• Self improvement is noted

• Acceptance of weaknesses

• Appreciation of strengths

• Clarity and direction

• How to Improve• Promote openness

• Create independence

• Permit more self-direction

• Establish additional goals

• Discuss additional projects

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What is Groupthink?

• Groupthink is also referred to as ‘groupness’

• Groupthink is a concept whereby loyalty within the team may prevent individual members from disagreeing publicly with suggested courses of action while privately opposing such suggestions

• The desire to ‘hold the group together’ may result in poor objective decision making

• “The more amiability and ‘esprit de corps’ among members, the greater the danger that independent critical thinking will be replaced by groupthink” Irving Janis, 1971 ‘Psychology Today’

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Other Team problems

• Floundering

• Dominant participants

• Overbearing participants

• Negative nellies

• Opinions as facts

• Shy members

• Jump to solutions

• Attributions

• Put-downs

• Wanderlust

• Feuding

• Risky-shift

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Floundering

• Problems• Team direction is unclear

• Members seem overwhelmed

• Decisions are postponed

• Fixes• Leader must provide clarity and direction

• Review the team purpose with members

• Ask members how the team can proceed

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Dominant Participants

• Problems• Members interrupt each other

• Members dominate conversations

• Members talk too much and too long

• Fixes• Enforce rules and protocols for sharing

• Structure the discussion

• Set time limits for sharing ideas and concerns

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Negative Nellies

• Problems• “We tried that already and it didn’t work”

• Members become defensive of their turf

• Unable to take suggestions or respond negatively

• Fixes• Find alternatives and hybrids to historical suggestions

• Ask if others are experiencing the same feelings

• Create buckets for new ideas and new criticisms

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Opinions as Facts

• Problems• Members try to push opinions as facts

• Members express assumptions as facts

• Unwilling to have their opinions questioned

• Fixes• Ask for substantiation of opinions

• Use assumption-busting tools

• May require private meeting with team leader

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Jumping to Conclusions

• Problems• Decisions are made due to deadlines rather than logic• Decisions are made in the absence of (good) data• Quantity is more important than quality

• Fixes• Allocate enough time to allow for thorough thought

and consideration• Reinforce the need for appropriate metrics and

analytics• Work through priority matrices to elevate solutions

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Wanderlust (Drift Happens)

• Problems• Conversations become too tangential

• Sensitive topics and issues are avoided (round-speak)

• Difficult to stay on track (topic-drift)

• Fixes• Keep responses short and keep directing back to the

topic

• Work up to sensitive topics from the bottom

• Follow a written agenda

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Characteristics of an effective project team

• Clear purpose

• Informality

• Participation

• Listening

• Civilized disagreement

• Consensus decisions

• Open communication

• Clear roles and work assignments

• Shared leadership

• External relations

• Style diversity

• Self-assessment

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Thomas-Kilman Conflict Modes

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• Competing – you lose, I win

• Avoiding – you lose, I lose

• Collaborating –you win, I win

• Accommodating – you win, I lose

• Compromising –no clear winners or losers

Competing Collaborating

Compromising

Avoiding AccommodatingAss

ertiv

enes

s

Cooperation

Key concept . . .

• The Andon Cord

• Recognize that there is a problem

• Empower

• Accountable

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Communication .. Plan for the day

• Huddle• Before clinic session or beginning of the day

• Include doctor (provider), medical assistant, scheduler, others….???

• Review what is about to happen

• Take a look at what happened yesterday

• Use as teachable moment

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The big question

What can I do to help the employee do the job better and achieve developmental goals?

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Coaching

• Strengthen communication between you and the employee

• Help the employee attain performance objectives

• Increase employee motivation and commitment

• Maintain and increase the employee’s self-esteem

• Provide support

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Questions to consider• How is the employee expected to perform?

• Does the employee understand these expectations? Why or why not?

• Does the employee know the performance is marginal? How do you know?

• Are there obstacles beyond the employee’s control? Can you remove them?

• Has the employee ever performed this task satisfactorily?

• Is the employee willing and able to learn?

• Does satisfactory performance result in excessive work being assigned?

• Does unsatisfactory performance result in positive consequences such as an undesirable task being performed?121

Coaching behaviors

Focus on behavior, not personality

Ask the employee for help in problem identification and

resolution. Use active listening to

show you understand.

Set specific goals and maintain

communication

Use reinforcement techniques to

shape behavior

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Some Measurements

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Definition of Terms

• FTE = full time equivalent, 40 hours per work week

• Measures of central tendency• Mean = average (total value/count)• Median = data point, true center of count

• Standard deviation = measure of variation, cluster around the mean

• Percentile (%tile) = relative position of other data point: (number of values above/below a specific value) +/- 0.5 / total number of values * 100%

• Count – N/n

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Benchmarking Defined

• Benchmark• A systematic, logical and common-sense approach to

measurement, comparison and improvement• A comparison to a standard

• Benchmarking• Copying the best, closing gaps and differences, and

achieving superiority• Identifying, understanding, and adapting best practices

and processes that will lead to superior performance (www.dti.gov.uk/benchmarking)

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Two key principles

1. If you don’t measure it, you can’t change it

• Description• Comparison• Context

2. If you don’t value it, you won’t change it

• Benefit

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Reasons/benefits

• Increase understanding of operations

• Gain or maintain competitive advantage and industry superiority

• Adopt best practices from any industry into organizational processes

• Uncover new concepts, ideas, and technologies

• Objectively evaluate performance strengths and weaknesses

• Observe where you have been and predict where you are going

• Convince internal audiences of the need for change127

10 steps to benchmarking

1. Determine what is critical to your organization’s success

2. Identify metrics that measure the critical factors

3. Identify a source for internal and external benchmarking data

4. Measure your practice’s performance

5. Compare your practice’s performance to the benchmark

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10 - continued

6. Determine if action is necessary based on the comparison

7. If action is needed, identify the best practice and process used to implement it

8. Adapt the process used by others in the context of your practice

9. Implement new process, reassess objectives, evaluate benchmarking standards and recalibrate measures

10. Do it again – benchmarking is an ongoing process, and tracking over time allows for continuous improvement!!!

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Performance ExpectationsQuality Expectation Target

Respond to phone within 3 rings 95%

Deliver four elements of the greeting

100%

Place caller on hold for no longer than 1 minute

95%

Minimal abandonment of calls <5%; 0% after 20 seconds

Greet with smile and by name within 45 seconds of patient arrival

100%

When patient visit is delayed by more than 20 minutes advise, give options and apologize

100%

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Workflow optimization“Right size” your workforce

(Cross train!)

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PATIENT FLOW STAFF PERFORMANCE EXPECTATIONSPractice Operations Task Workload Range*Appointment scheduling with no registration 75-125 calls per dayAppointment scheduling with full registration 50-75 calls per dayPre- or site registration with insurance verification 60-80 patients per dayCheck-in with registration verification only 100-130 patients per daySite check-in with registration verification and cashiering only 75-100 patients per dayCheck-out with follow-up scheduling, charge entry and cashiering 60-80 patients per dayCheck-out with scheduling and charge entry 70-90 patients per dayCheck-out with scheduling and cashiering 70-90 patients per daySurgery scheduling 25-30 surgeries per dayReferral specialist (inbound or outbound referrals) 70-90 patients per dayNurse triage 65-85 calls per dayNurse/MA rooming patients and assisting physician 22-30 patients per day

* Range will depend on patient population, system, level of automation, and work processes utilized at the practice .Source: Mastering Patient Flow, Woodcock, 2009.

Measuring quality/costs

• Acceptable quality

• Quality is expensive

• Tolerating some defects are acceptable since the cost of repair is greater than the expected outcome

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Four categories of quality costs

1. Prevention – incurred to prevent defects• Training

2. Appraisal – incurred for monitoring and inspection• Quality control and audits

3. Internal failure – incurred when a defect is found before service provided

• Re-work

4. External failure – incurred for providing service to customer

• Warranty, loss of goodwill, other talking, choosing a competitor, law suits

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Cost of quality report

• Volume from one period to next

• Cost to provide service changes from one period to another or to budget

• Percentage change is significant

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Project Charter

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What is a Project Charter

• A Project Charter is a written document that is used as a foundational guide for conducting a process improvement project

• Establishes rules of game

• What project includes, what it doesn’t (boundaries)

• Goals, constraints, success criteria

• It consists of:• Project scope• Project assurance• Project resources• Project limits and other expectations• Approvals

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Project Charte

r

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Project Name Start Date 

Team: Leader

Members

Facilitator if needed:

Stakeholders

Problem statement or business case

Purpose/Goal (business need)

Objectives (measurable) 

Assumptions 

Risks

Deliverables 

Boundaries

Task Assignment/du

ties

Due Date To Whom

Milestones

Communication strategy

Budget

Final presentation Who: Date

Recommendation

Accepted/revision: Date:

Benefits of a Project Charter

• Establishes rules of game

• What project includes, what it doesn’t (boundaries)

• Goals, constraints, success criteria

• Negotiations

• Buy-in

• Formal agreements

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A Good Project Charter

• Describe issues or situation motivating the project

• Describe the objective (outcome) of the project

• Identify the customers (patients, staff, payers, etc.)

• Stipulate boundaries (specific targets and/or goals)

• Estimate financial impact

• Define what the final deliverable will look like

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Gantt ChartIssue Responsible Goal March April May June

ITDeni & Fran

Remove firewalls, insertion and download work

EMRTeam

Install and use EMR 17 x

Forms/iPro toolsMichelle

Review and begin using the iPro forms

X X Complete

Pre‐Authorizations

Danielle/FranEach payer requirements, utilize electronic options

check check Follow procedure

Reimbursement and Managed Care Contracting

Deni with help from Michelle and Peter

Need to understand current contracts, reimbursement levels, as well as possible change in terms

X X Implement

MetricsDeni

Assess history of iPro use, find reports that will generate current and future measurements

History Test Implement x

Patient scheduleDoctors

Use 5 day cycle, find days of week to use the 7 current units to maximum level

Model and test Begin Check 

ProtocolDoctors

Determine criteria for iPro use, train staff, staff remind of possible candidates

Review materials and standardize

x x x

StaffingDeni

Front desk ‐ numbers, train & cross train

Build case for 3 FTE's

Fill in 3rd FTE

iPro useTeam

Do at least five in March to test schedule, 200 by year end

5 5 10 20

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Getting started

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Is Your Practice Ready –and Conclusion

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Understanding Complexity

• A complex system is a system composed of interconnected parts that as a whole exhibit one or more properties that are not obvious from the properties of the individual parts.• Diverse, interdependent, connected, adapting entities

• Complex systems:• Are unpredictable

• Produce large events

• Are very robust

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The Two Litmus Tests

• Compliance risk• Variability regarding comparisons to national averages• Reporting levels compared to set standards (i.e., FMV)• Usage violations and/or warnings

• Financial opportunity• Variability may point to missing opportunities• Waste increases costs and reduces quality• Cycles can be shortened, improving volume without costs

• Compliance risk should always be considered first• The financial consequences can be devastating

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Does Process Improvement Always Work?

• NO

• In addition to a lack of buy-in by senior management and owners, here are the biggest reasons for failure• Lack of a specific target or goal• Failure to define what constitutes success• Ignoring the chaos that may be created during interactions• Confusing improvement in a process with improvement of the

system• Assuming that the final output will actually result in the final

goal• Failure to associate how improvement moves toward the vision

for the organization

• Not all goals are appropriate for process improvement

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Is Every Project the Right Project?

• Clearly, NO• There are such things as bad projects

• The wrong project will, first of all, ‘feel’ bad

• It will not have a definable shell

• It will be difficult, if not impossible, to separate it from other problems

• It will be difficult to define success and therefore measure success

• A ‘wrong’ project will waste resources and make it difficult to sell a new project in the future

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Are You Performance Oriented?

• Do you only go after the low-hanging fruit?

• What percent of your time and resources are committed to continuous process improvement?

• If you are ready to engage, ask yourself:• What processes are ripest for an improvement strategy?• How can we make the greatest impact with the least

amount of resource expenditure?• To what degree can we increase quality and reduce

cycle times?

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Starts with Commitment

• Vision – “the articulation of the image, values, direction, and goals that will guide the future of the organization”

• Mission – the intersection of the founding principles and the environmental scan

• Stretch Goals

• Empower teams

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The Readiness Assessment

• Assess the outlook and goals of the organization• Is there a consensus of vision?• Do we have the resources to meet our goals?• Are we willing to do what it takes to change?

• Evaluate the current state• What do we look like right now?• What is our current level of efficiency?• Do we have the resources to start the project?

• Review the capacity for change and improvement• How flexible are we when it comes to change?• What is our capacity for growth and improvement?• What existing issues exist that would constrain our efforts?

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Don’t forget

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Meet the needs of your customer,

they are human

and not numbers!

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Change – Let’s think Transition

Change

• An external event, a shifting of circumstances in the world created by a natural occurrence or a human-made choice• Disruption in expectations• External event

• Related to circumstances and situations

• Sometimes connected to a decision or choice

Transition

• Adaptation, the human process of getting used to the change• Psychological reorientation

to the change event

• Internal process

• Related to a state of mind, a sense of identity

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It’s OK to fail …

• Accept failure as a natural part of doing business

• Remove structural obstacles to reduce the objective risks of a failed venture

• Turn failure into fodder: fail small, fail fast, & fail cheaply

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“Those who don’t take risks tend to have two majormistakes a year, those who do take risks tendto have two major mistakes a year!” Drucker

Benefits of Improvement

Decrease average time patient spends in clinic from two hours to an hour or less

Satisfied patients (customers)

Eliminate duplicated duties

More effective use of staff & resources

Increase efficiency

Increase quality

Satisfied staff

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Where can you go from here?

• Yellow belt

• Green belt

• Black belt

• Master black belt

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155

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“Strive not to be a success, but rather to be of value.”

Albert Einstein