maximizing roi during a lean transformation

Maximizing ROI During A Maximizing ROI During A Lean TransformationLean Transformation

Typical ROI ParametersTypical ROI Parameters

CostCost StartupStartup RecurringRecurring ConsultantsConsultants PersonnelPersonnel

Expected Returns/BenefitsExpected Returns/Benefits Generally $$$Generally $$$ Could be outcomesCould be outcomes Customer/Employee SatisfactionCustomer/Employee Satisfaction

TimeTime When will we achieve benefits to cover costsWhen will we achieve benefits to cover costs

To Accelerate ROITo Accelerate ROI

↓ ↓ Expense or CostExpense or Cost ↓ ↓ Time Time Modify Goals – Focus on areas with Modify Goals – Focus on areas with

greatest opportunitygreatest opportunity

Lean TransformationLean Transformation

Built in ROIBuilt in ROI ““Only improvement methodology Only improvement methodology

which doesn’t rely on a catastrophic which doesn’t rely on a catastrophic event as a catalyst for change”event as a catalyst for change”

““Ongoing continuous improvement Ongoing continuous improvement through the relentless elimination of through the relentless elimination of waste”waste”

True Lean ROITrue Lean ROI

Dependent on:Dependent on: Staff EngagementStaff Engagement Cultural ChangeCultural Change Success of Kaizen EventsSuccess of Kaizen Events Sustainment of ImprovementSustainment of Improvement

Cultural TransformationCultural Transformation

Cultivating an Cultivating an entire staff of entire staff of “Wasteologists”“Wasteologists”

The value of an The value of an engaged and engaged and aware aware workforce workforce working in the working in the least-waste way least-waste way is is immeasurable immeasurable and invaluableand invaluable

$$$$$$

Staff SatisfactionStaff Satisfaction Patient SatisfactionPatient Satisfaction

Patient SafetyPatient Safety$$$$$$

Staff SatisfactionStaff Satisfaction Patient SatisfactionPatient Satisfaction

Patient SafetyPatient Safety

QUALITYQUALITYImproved processImproved process

Improved flowImproved flowImproved informationImproved information

Transformation TheoryTransformation Theory

Transformation Theory vs. Transformation Theory vs. Healthcare Challenges of TodayHealthcare Challenges of Today

Increased pressure to maximize Increased pressure to maximize returns due to reductions in returns due to reductions in reimbursements and ever changing reimbursements and ever changing healthcare standardshealthcare standards

Demand ROI that are measureable, Demand ROI that are measureable, sound, profitable, and immediatesound, profitable, and immediate

Jacobi Medical Center CampusJacobi Medical Center Campus

FY10 Jacobi NCB

# of Beds 479 243

Discharges 22,100 9200

Outpatient Practices

Visits

386,000 200,000

Emergency Department

Visits

113,400 61,000

Ambulatory Surgery Cases

9,500 2,700

Statistical ProfileStatistical Profile

Jacobi Specialty ProgramsJacobi Specialty Programs

• Emergency

Medicine

• Regional Snakebite

Center

• Level 1 Trauma

Center

• FAA-Approved

Helipad

• Pediatric Trauma

Center

• PICU

• Hyperbaric

Chamber

• NYS-Designated

Regional

• Perinatal Center

• Level III NICU

• Burn Service

• NYS-Designated Stroke

Center

• Medical Oncology

Program

• Breast Service

• Rehabilitation Medicine

• Pediatric Surgery

• Craniomaxillofacial

Surgical Institute

• Cardiac Cath Lab

• Bariatric Surgery

Program

Lean Kaizen EventsLean Kaizen Events

0

100

200

300

400

500

600

700

800

2008 2009 2010

StaffParticipation

# of Kaizen Events # of Staff Participation

149 1478

Examples of Jacobi ImprovementsExamples of Jacobi Improvements

Reduced Dwell Time in ED 3 hours Increased volume of surgeries Increased billing due to a better

registration process Increased Medicaid applications Reduced patient travel, improving

patient safety

OPD Revenue Cycle: OPD Revenue Cycle: Reason For Action Reason For Action

Reasons for Action

• COLLECT ALL EARNED REVENUE

• ONLY COLLECTING 71% of OPD REVENUE

• HIGH VOLUME of DENIALS

• $20 MILLION BUDGET DEFICIT

• HIGH LEVEL of PATIENT ,PROVIDER and EMPLOYEE DISSATISFACTION

Business CaseBusiness Case

••Increase RevenueIncrease Revenue

••Creativity Before CapitalCreativity Before Capital

••Better Understanding of Better Understanding of Work FlowWork Flow

••Better Plan for Better Plan for ImprImpr

••Observe the ProcessObserve the Process

••Identify Front End to Identify Front End to Back End Process for Back End Process for Revenue Revenue

Value StatementValue Statement

•• Respect Respect

•• Complete Complete understanding of understanding of financial responsibilityfinancial responsibility

•• Fast RegistrationFast Registration

•• One stop shoppingOne stop shopping

•• Correct SchedulingCorrect Scheduling

Key RequirementsKey Requirements

•• HIPAAHIPAA

•• EMTALAEMTALA

•• PAR PAR MgdMgd Care Care ContrContr

•• Medicaid / Medicare Medicaid / Medicare Rules/TimeframesRules/Timeframes

•• Corp Mission StmtCorp Mission Stmt

•• Continuum of CareContinuum of Care

•• MD CredentialingMD Credentialing

Measurements Measurements

• % OPD Collections• % of Clean Claims• % Incurred Denials / # of Visits• Revenue• Absenteeism• # OPD Open Visits

• Patient• Staff • Equipment• IT Systems

INPUTSINPUTS

•• General vendors General vendors •• Outpatient PracticesOutpatient Practices•• EquipmentEquipment

SUPPLIERSSUPPLIERS

•• Improvement Improvement Of patient health Of patient health & Visit Satisfaction& Visit Satisfaction•• Collect Earned Collect Earned •• Revenue Revenue

OUTPUTSOUTPUTS

•• Patient Patient

CUSTOMERSCUSTOMERS

••SchedulingScheduling••RegistrationRegistration••Patient EncounterPatient Encounter••Redirect/Return VisitRedirect/Return Visit••ZZ--outout••Close Visit TimelyClose Visit Timely••BillingBilling••FollowFollow--upup••Payment Payment

PROCESSPROCESS

Trigger:Trigger:Patient Requests AppointmentPatient Requests Appointment

Done:Done:Get Appropriate Payment Get Appropriate Payment

OPD Revenue Cycle:OPD Revenue Cycle: Initial State Initial State

Initial State

• INEFFICIENT OUTPATIENT SERVICES

• NOT BILLING for ALL PROVIDER SERVICES

• INEFFECTIVE CODING SYSTEM

• POOR COMMUNICATION PLAN

• POOR REFERRAL SYSTEM

• COLLECTION RATE IS < 72% 160,000# of Visits per Year /

Medicine & Surgery

74%% Payments within 45

Days

62,967 Cash Receipts Reported

(OPD) FY08 (000)

70.16Avg Payment per Visit

50%Collectability all OPD

Services

Base Line Base Line MeasurementsMeasurements

Year 1 - 11 RIEsYear 1 - 11 RIEs

2008 - 2009

Apr 29, 2009 – May 1, 200910. Ophthalmology Out patient Practice Throughput

Mar 23, 2009 – Mar 27, 20097. Managed Care Denials and Appeals

Dec 19, 2008 – Dec 23, 20086. Out Patient Physician Documentation

Nov 21, 2008 – Nov 25, 20085. Rehabilitation and Ophthalmology

Oct 24, 2008 – Oct 28, 20084. Out Patient Managed Care Billing and Denials

Apr 20, 2009 – Apr 24, 20099. Oncology Billing

May 04, 2009 – May 08, 20098. Rules of Engagement

Sept 21, 2009 – Sept 25, 200911. Network Redirection Policy Implementation

Sept 22, 2008 – Sept 26, 20083. Appointment Scheduling

July 28, 2008 – Aug 1, 20082. Standardizing Schedules and Template Process For the Adult Primary Care Practices

June 9, 2008 – June 13, 20081. Ortho

OPD Revenue Cycle

JACOBI RIEs

OPD Revenue Cycle Value Stream:OPD Revenue Cycle Value Stream:Confirmed StateConfirmed State

Confirmed State

• Standardized Process

• Increased Revenue

• Increased Patient Satisfaction

• Improved Employee Morale

97,00062,967 Cash Receipts Reported (OPD)

FY08 (000)

TBD70.16Avg Payment per Visit

85%74%% Payments within 45 Days

160,000160,000# of Visits per Year / Medicine &

Surgery

85%50%Collectability all OPD Services

Target Target Base Line Base Line MeasurementsMeasurements

OPD Revenue Cycle MetricsOPD Revenue Cycle Metrics

JacobiMonthly Breakdown OPD

1000

3000

5000

7000

9000

11000

Month

Cas

h R

ecei

pt

FY08

FY09

FY10

FY11

Linear (FY08)

Linear (FY10)

Linear (FY09)FY08 5392 5128 4603 1339 3509 4021 4384 4197 10087 5599 5487 5764

FY09 4881 5082 4948 4293 4357 5329 4766 5440 6300 10227 5529 6210

FY10 4680 7137 6944 4948 5353 6245 5638 5084 6727 6594 11739 5876

FY11 5796 5436 5416 5768 9010 8428 5951 5830

July August September October November December January February March April May June

OPD Revenue Cycle MetricsOPD Revenue Cycle Metrics

40000

45000

50000

55000

60000

65000

70000

75000

80000

FY08 FY09 FY10 FY11

JMC

20000

22000

24000

26000

28000

30000

32000

34000

36000

FY08 FY09 FY10 FY11

NCB

** FY11 ↑ 8% ↑ 8% Vs FY10 YTDVs FY10 YTD

** FY11 ↑ 5% ↑ 5% Vs FY10 YTDVs FY10 YTD

AED Hospital Wide Flow: AED Hospital Wide Flow: Reason For ActionReason For Action

Reason for Action

• To enhance patient and Staff Satisfaction

• To enhance patient safety

• Poor utilization of professional resources

• Insufficient or inappropriate care

• Suboptimal financial performance

• We are NOT the ED of choice for the Bronx and lower Westchester.

Business CaseBusiness Case

Our beginning efforts at Our beginning efforts at process improvement process improvement will begin with a focus in will begin with a focus in the Emergency Dept. the Emergency Dept. We plan to decrease We plan to decrease dwell time, which will dwell time, which will correlate with an overall correlate with an overall decrease in LOS and decrease in LOS and therefore increase therefore increase capacity in the inpatient capacity in the inpatient units by reducing units by reducing duplication of efforts. duplication of efforts.

Value StatementValue Statement

The patients accessing the The patients accessing the JMC ED value high quality, JMC ED value high quality, timely, and life saving timely, and life saving emergency care in a emergency care in a respectful appropriate respectful appropriate environment, This will environment, This will provide the patient with provide the patient with complete continuity of complete continuity of care covering the full care covering the full spectrum of their spectrum of their healthcare needs. healthcare needs.

Key RequirementsKey Requirements

••SafetySafety

••ConfidentialityConfidentiality

••Regulatory AgenciesRegulatory Agencies

••ProfessionalismProfessionalism

••Educational needsEducational needs

••Appropriate treatment Appropriate treatment and competencies.and competencies.

Measurements Measurements

••Time Door to FloorTime Door to Floor

••Time Door to DoorTime Door to Door

••Walkouts %Walkouts %

••Waiting TimeWaiting Time

••# of Patients# of Patients

••Growth in RevenueGrowth in Revenue

• Patient• Staff • Equipment• IT• Ambulatory• Nursing Homes

INPUTSINPUTS

•• General vendors General vendors •• EMSEMS

SUPPLIERSSUPPLIERS

•• Finance rewardFinance reward•• Wellness of patientWellness of patient•• Safe dischargeSafe discharge•• Pain freePain free•• Physical need metPhysical need met•• Focused on patientFocused on patient•• On timeOn time•• Plan of CarePlan of Care•• Staff Moral Staff Moral •• AppreciationAppreciation•• EducationEducation•• Good work Good work envirenvir..

OUTPUTSOUTPUTS

•• PatientsPatients•• TelemetryTelemetry•• Met Surge UnitsMet Surge Units•• Specialty Units Specialty Units

CUSTOMERSCUSTOMERS

••TriageTriage••Registration Registration ••ED decision to admitED decision to admit••AdmissionAdmission

••EvaluationEvaluation••Treatment Treatment ••Testing / Diagnostic / imaging/LabsTesting / Diagnostic / imaging/Labs••DischargeDischarge••TeachingTeaching••Contacting Admitting ServiceContacting Admitting Service••DocumentationDocumentation••Waiting for consultantsWaiting for consultants••Communication (beds)Communication (beds)••Availability of environmentAvailability of environment

••Support servicesSupport services••EscortEscort••EnvironmentalEnvironmental••SecuritySecurity

••Service Adjudication Level of Care Service Adjudication Level of Care ••SchedulingScheduling

PROCESSPROCESS

Trigger:Trigger:Patient ArrivalPatient Arrival

Done:Done:Patient leaves the ED Patient leaves the ED

AED Hospital Wide Flow: AED Hospital Wide Flow: Initial StateInitial State

Initial State• “Hospital within a hospital” ED is a complex system

• 5 hrs T+R (Excluding wait times) 10 hours dwell time for admissions

• Late discharges / extended LOS

• Low collection rate

• Too many admission denials

• Incompatibility of IT systems

• Safety net providor

0:00:001:00:002:00:003:00:004:00:005:00:006:00:007:00:008:00:009:00:00

10:00:0011:00:0012:00:0013:00:0014:00:0015:00:0016:00:0017:00:0018:00:0019:00:0020:00:0021:00:0022:00:0023:00:0024:00:0025:00:00 JACOBI ED ADMISSION DWELL TIME

Door-to-Admit Decision

Overall Dwell Time ED

Triage to SMAR

Treat & Release Intervals All Patients

0:32 0:29 0:20 0:23 0:21 0:24 0:27 0:23 0:23 0:23 0:20 0:20 0:26

1:47 1:531:25 1:34 1:24 1:27 1:28 1:45

1:21 1:16 1:10 1:25 1:34

2:40 2:40

2:342:38 2:41 2:52 2:43

3:05

2:41 2:432:37

2:382:37

0:00

1:12

2:24

3:36

4:48

6:00

Month

Ho

urs

:Min

ute

s

entry-to-d/c

reg-to-entry

triage-to-reg

AED Hospital Wide Flow: AED Hospital Wide Flow: Target StateTarget State

Target State

• Become ED of choice for Bronx Westchester• 2 Hr 45 min Treat to release • 7 hr door to floor time• Improve HCAPs score to above 90th %tile • Reduce LOS by 1 day• Increase ED collectability to 80%• Meet or exceed industry standards for

admissions denials (3% of admissions)• Maximize utilization of IT systems• 100% ED chart reconciliation

MeasurementsMeasurements TargetTarget Comments Comments

Time Door to Floor 7 hr TPOC target 5 hours

Time Door to Release 2 hr 45 m

Walkouts % < 3 %

Reduction of Waiting Time

40%Pending evaluation of data and way

to measure

Year 1: 11 RIE’sYear 1: 11 RIE’s

2008 - 2009

July 20, 2009 – July 24, 200910. Transfer of Patients Through ICUs

Mar 23, 2009 – Mar 27, 20097. AED-Hospital Wide Flow Admitting

Dec 19, 2008 – Dec 23, 20086. Medicine and Surgery Admission Decisions in ED

Nov 21, 2008 – Nov 25, 20085. AED HIM and Chart Reconciliation Open Visit

Oct 24, 2008 – Oct 28, 20084. AED Logistics and Clinical Support

June 15, 2009 – June 19, 20099. Utilization of Space in Building 8

Apr 13, 2009 – Apr 17, 20098. AED-Hospital Wide Flow Discharge Planning

Sept 21, 2009 – Sept 25, 200911. Treat and Release Patients – Urgent Care

Sept 22, 2008 – Sept 26, 20083. Patient Property “Watch My Stuff”

July 28, 2008 – Aug 1, 20082. Patient Discharge and Chart Processing

June 9, 2008 – June 13, 20081. Registration and Triage in the AED

AED Hospital Wide Flow Value Stream

JACOBI RIEs

AED-Hospital Wide Flow:AED-Hospital Wide Flow:Confirmed StateConfirmed State

Confirmed State

• Performed all RIE identified in the Value Stream• Satisfied patient• Satisfied staff • Sustained improvements • Standardize process • One patient at a time• Zero defects• Coordinate patient demand and bed availability

5.256.25Average Length of Stay

MeasurementsMeasurements Base Line Base Line TargetTarget Comments Comments

Time Door to Floor 11 hr 7m 7 hr TPOC target 5 hours

Time Door to Door 4 hr 32 m 2 hr 45 m

Walkouts % 5.1% < 3 %

Waiting Time TBA 40%Pending evaluation of data and way to

measure

# of Patients (annually) 62,917 TBD Monitor growth in ED patients

CY11 5.5 LOS

Current Value Streams at Jacobi Current Value Streams at Jacobi Medical Center/NBHNMedical Center/NBHN

Nursing - 8 RIEs Radiology – 6 RIEs Peri-Operative Services – 11 RIEs Admitted Patient-Medicine – New Value

Stream Admission/Readmission – 4 RIEs Adult ED Flow – 16 RIEs Behavioral Health Services/Rehabilitation

– 1 RIE

Current Value Streams at NCB Current Value Streams at NCB Medical Center/NBHNMedical Center/NBHN

Nursing - 4 RIEs Revenue in Process – 5 RIEs Women’s Health Services – 10 RIEs Peri-Operative Services – 7 RIEs Medicine – 4 RIEs Behavioral Health Services – 6 RIEs

Maximizing your ROIMaximizing your ROI

Directly related to the success of Directly related to the success of Kaizen EventsKaizen Events

Stacking the Deck for SuccessStacking the Deck for Success

Enterprise GoalsEnterprise Goals

Goals and Targets should be well Goals and Targets should be well defined, inter-related, and support defined, inter-related, and support each othereach other

i.e. if financial performance ↑ but i.e. if financial performance ↑ but patient safety ↓, is this ok?patient safety ↓, is this ok?

LeadershipLeadership

Senior Leadership should be “All In”Senior Leadership should be “All In” Setting goals and participating activelySetting goals and participating actively Encourage and support true Encourage and support true

transparencytransparency Integrate Lean into all hospital-wide Integrate Lean into all hospital-wide

strategic planningstrategic planning

“You don’t know what you don’t know”

Choosing Lean Leader Choosing Lean Leader (Transformation Officer)(Transformation Officer)

Respected in the organizationRespected in the organization Well-KnownWell-Known Have established credentialsHave established credentials

““If you want something done, give it If you want something done, give it to a busy person to do”to a busy person to do”

Integration of Lean MessageIntegration of Lean Message

Consolidate meetings utilizing Lean Consolidate meetings utilizing Lean Metrics and hospital wide dataMetrics and hospital wide data

Agenda at all:Agenda at all: Hospital Wide MeetingsHospital Wide Meetings Service Line MeetingsService Line Meetings Executive MeetingsExecutive Meetings AffiliateAffiliate CAB MeetingCAB Meeting Board MeetingsBoard Meetings

LEAN!


Not the “Flavor Of the Month”Not the “Flavor Of the Month” ““Lean is the Lean is the wayway we work, not in we work, not in

additionaddition to how we work” to how we work”

AAdvertisedvertise

CCommunicateommunicate

EEducateducate


Ongoing Lean CurriculumOngoing Lean Curriculum Part of New Employee OrientationPart of New Employee Orientation Staff Engagement is critical and is the Staff Engagement is critical and is the

key component to maximizing ROIkey component to maximizing ROI As time ↑ and more staff are actively As time ↑ and more staff are actively

practicing Lean, improvement will practicing Lean, improvement will become the way you work and good become the way you work and good won’t be a barrier to greatwon’t be a barrier to great

Aim for Early SuccessAim for Early Success

““Low Hanging Fruit”, “Fruit on the Low Hanging Fruit”, “Fruit on the Floor”Floor”

Sustainment will fertilize the treeSustainment will fertilize the tree Early successes will support spread Early successes will support spread

and enhance the Lean and enhance the Lean transformationtransformation

Metrics for SuccessMetrics for Success

Metrics should be easily defined and Metrics should be easily defined and measurable using existing datameasurable using existing data

““Figures don’t lie, liars figure”Figures don’t lie, liars figure”

Understand the genesis of the Understand the genesis of the data and how it originatesdata and how it originates

Driver MetricsDriver Metrics

Use driver metrics:# of steps saved# of completed

registrations# follow-up phone calls

To ultimately reach targets:Length Of Stay

ReductionRevenue

Length Of Stay

# of Steps# of

handoffs

The best Kaizen Events are….The best Kaizen Events are….

Events that are well choreographed Transformation should not be a random

sequence of events with the results dictated by chance

Plan, Plan, Plan Select proper staff, times, and data Pre-meetings, targets, metrics

“The more I practice the luckier I get”- Gary Player

Scoping EventsScoping Events

Scope the Kaizen Events as tightly as possible

“A mile deep and an inch wide” “Do not boil the ocean” It is the collective changes and

dovetailing of events that will bring the greatest returns

Select subject matter experts at all levels

Lean Words to Live ByLean Words to Live By

Listen! Listen! Listen! Walk Around! Observe!

You don’t know what you don’t know, but your staff does

SustainmentSustainment

Sustainment is the key to a successful transformation and greatly accelerates ROI

Standard work is the critical linchpin for sustainment

Demand It!

Ensuring Lean SuccessEnsuring Lean Success

Assign strong, responsible parties to monitor past event progress/completion plans and follow ups

Have regular scheduled program reviews Target adjustments Identify new areas of focus Priority shifts Future schedules

Lean Lessons to ShareLean Lessons to Share

Creativity Before Capital Flexibility over rigidity There are no “Bad” Events Avoid the “doing more with less”

trap Creates resentment, excuses, makes

bad processes more inefficient, and promotes mediocrity

Don’t Be Shy!!!Don’t Be Shy!!!

Celebrate your success Don’t be afraid to highlight true

progress

Questions? Comments?