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Practicing Six Sigma for Medical Group Practice Success
Cardiovascular ConsultantsPasteplus Improvement Team
Author: Mark Stewart
Heartland Health
HEALTHY CHOICESHealthy Lives Heartland Health
Heartland Health• Tertiary care regional hospital• 21 county service area; 285,000 people• Services include:
– Medical group practices– Health maintenance organization (HMO)– Preferred provider organization (PPO)– Acute and post acute care services– Regional community foundation– Regional clinics and affiliations
HEALTHY CHOICESHealthy Lives Heartland Health
Heartland Health• 70+ employed physicians• 430,000 outpatient visits
– Includes 250,000 Medical Group Practice (MGP) visits
• 26,000 covered HMO/PPO lives• 42,000 annual emergency room visits• 19,000 annual hospital discharges• 2,600+ employees
HEALTHY CHOICESHealthy Lives Heartland Health
Heartland Health
isionV-“Best and safest”-“Healthy and productive”
Mission-Improve health of individuals and communities-Right care, right time, right place, right cost-Outcomes second to none
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Project • This project involved cardiology services at
Heartland Health. We were missing charges and the times between delivery services and dictation, transcription, report delivery and charge entry were very high.
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Team Membership
• Steve McCamy • Dottie Bray • Scott Koelliker• Ellen Ellis• Donna Gibson• Dr. Hindupur• Regina Tillman• Cheryl Baldwin
• Dr Griffin• Carrie Till• Lindsey Minton• Vanessa Strasser• Deb Webb• Lori Stickler• Mark Stewart
HEALTHY CHOICESHealthy Lives Heartland Health
Project Timeline• Kick off Meeting: July 11, 2002
• P roblem Phase: August 9, 2002• A nalysis Phase: September 26, 2002• S olution Phase: November 22, 2002• T ransition Phase: December 27, 2002• E valuation Phase: January 10, 2003
Ongoing
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Charge Throughput Process
Patient Services Rendered CodingDocumentation
DictationCharge Entry
Transcription
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Opportunity Statement• Opportunity to improve the timeliness,
accuracy, comprehensiveness, and efficiency of the charge throughput process resulting in cost savings, increased productivity and net revenue.
Problem statement• Charge throughput is not timely, accurate,
comprehensive or efficient.
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Current and Desired Sigma
Yield Sigma Yield Sigma•Physician Productivity 97.90% 3.54 99.30% 3.99• • •Timely Charge Entry of 5 days from Date of Service 2.50% -0.46 90.30% 2.8• • •1st pass accuracy of encounter form 92% 2.91 99.20% 3.91• •Comprehensive for services rendered 97.50% 3.46 99.75% 4.31• • •Efficiency: Clerical FTE’s per 10,000 Work RVU’s 38th Percentile of MGMA 2.61 25th Percentile 1.96
Current Stats Desired Stats
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SIPOCdeveloped to present an “at-a-glance” view of important variables to the work flow.
• Supplier – the person/group providing key information, materials, or other resource to the process
• Input – the “thing” provided• Process – the set of steps that transforms – and ideally,
adds value to – the Input• Output – the final product of the process• Customer – the person, group, or process that receives the
Output
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Suppliers Inputs Process CustomersKey Quality
Characteristics
❒ Physician❒ Clinical Staff❒ Cath Lab Staff❒ Heart Ctr Staff❒ Outreach Staff
Patient Services Rendered
Outputs
Document Encounter & Services
Transcription
Match documentation with Encounter forms
❒ See Below
❒ Charge Form Coded and Entered into Computer
❒ Patient❒ Physician❒ Ref. Physician❒ Patient Financial
Services
❒ Accurate❒ Timely❒
Comprehensive
Coding performed
❒ Documentation❒ Encounter Form❒ Cath Lab Log❒ Non-invasive Log
Entry of encounter form into Computer
Dictation Transcribed Report
Coded Encounter
Output Subprocess Outputs Matched
Documentation
SIPOC Diagram
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Workout Teams• ICQC, Inc.
– CARES +• Core Service
– Outcomes Mgt• Access
– Scheduling– Communications
• Representation– Patient relations
• Economics– Cost of Service– Value for Service
• Staff & Support– Goal : Patient
Satisfaction• 25 % Improvement
• Provider Documentation– Goals
• One day turnaround time – DOS to Dictated – Dictated to
Transcribed• Reduce Transcription
Cost– Approx 15 %
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Analysis• Review previous reports• Cause & Effect Diagram• Cause & Effect Pareto• Collect data on Cause & Effect• Flowchart problem processes• ANOVA• Descriptive Statistics
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Review of Previous Projects• Reviewed PARM team measures for
practice– % of charges posted in 5, 10, 30, < 30 days– Encounter forms returned by coder– Additional charges found, not on enc. Form– Point of service collections– Write-offs: Contractual and Administrative
• Hospital Logs; Cath lab, Non-Invasive lab• Other MGP reports
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Cause and Effect (Fishbone)Diagram
• Used to trigger ideas and promote group brainstorming to list potential causes of the problem
• Rules of brainstorming apply• Causes are categorized and clarifies• Group multi-votes on causes
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Cause and Effect Diagram
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--
--
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-
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--
--
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Personnel
Machines
Materials
Methods
Measurements
Environment
Why is charge throughput not
opportune accurate, comprehensive or
efficient?
Phy s ic ian Coding Edu
Not enough s ta ff
Com m itm ent / M otiv a t
lac k ing by s ta ff
Trans c ription s taff
Ins uffuc ient Dr Codi
Com m unic ation Barrie
Student/Phy doc um ent
Com puters
AFM does not prev ent
dup l ic ate c harges
& Enc ounter form s
AFM s c hedul ing s oftw
Can' t s ee v is i t reas
CM S news
Chart Not Av a i lable
Inc ons is tent Proc es sSc hedul ing between c
Rework AFM
Dupl ic ate enc ounters
Trans c ription Delay
Inac c urate
Dic ta tion DelayHos p IntersInac urate: s pel l ing ,
Non m atc hing OrderinDupl ic a te res ul ts reDelay ed s c hedule fax
Dr not c om pleting HoOrdering Dr lac k o f
Outreac h Cl in ic s proNo s tandard d ic ta tio
No c om m unic ation bet
People
Machines
Materials
Methods
Methods
Environment
MGP Charge Throughput
Why is charge throughput not timely accurate, comprehensive or efficient?
HEALTHY CHOICESHealthy Lives Heartland Health
Pareto Chart Multivote Result of Cause and Effect
Coun
t
Perc
ent
C8
Count 3 2 2 2 2 2 2 2 2 28 1 1 1 1 1 3Percent 11 9 8
78 7 7 7 5 4 3 3 3 3
63 3 3 3 3 1 1 1 1 1
64
Cum % 11 20 28 36 43 49 56 61
5
65 68 71 73 76 79 81 84 87 89
5
91 92 93 95 96 100
5 4
Other
Orderi
n g Dr lac
k of D
x
Not en
ough s
taff
Compu
ters
Charg
e entr
y tria
l bala
nce d
oes n
ot lis
t mod
ifiers
AFM ca
n't se
e visit
reaso n
Transc
riptio
n staf
f
Team
wo rk am
ong PO
DS
Lost
charges
Inco
nsist
ent P
roce
sses
Duplica
te re
sults
Dr. Cod
ing Ed
ucati
on C
MS Med
ical N
ecessity
Commun
icatio
n
Comm b
etwee
n Dr &
Staf
f/Dr a
nd D
r
Attitud
e
No stan
dard
dicta
tion pr
ocess
for D
r
Hosp c
harg
e slip
s no t c
omp lete
Ou treac
h pr
oces
s vari
es
Commitmen
t/Moti
v ation
Chart
No t Ava
ilable
Duplica
te Cha
rges fo
r Serv
AFM du
plica
te ch
arges/E
F
Tran
scrip
tion D
elay
Dictat i
on D
elay
80706050403020100
100
80
60
40
20
0
Pareto Chart of C8
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-10 0 10 20 30 40 50 60 70
USLUSL
Cardiovascular Consultants Overall Currrent State Process Capability
USLTargetLSLMeanSample NStDev (Within)StDev (Overall)
Z.BenchZ.USLZ.LSLCpk
Cpm
Z.BenchZ.USLZ.LSLPpk
PPM < LSLPPM > USLPPM Total
PPM < LSLPPM > USLPPM Total
PPM < LSLPPM > USLPPM Total
6.0000 * *
20.0088678
4.985228.96243
-2.81-2.81
*-0.94
*
-1.56-1.56
*-0.52
*992625.37992625.37
*997523.49997523.49
*940981.26940981.26
Process Data
Potential (Within) Capability
Overall Capability Observed Performance Exp. "Within" Performance Exp. "Overall" Performance
Within
Overall
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DataOne-way ANOVA: DOS to Entry versus Provider
Analysis of Variance for DOS to ESource DF SS MS F PProvider 5 7054.7 1410.9 20.37 0.000Error 666 46129.6 69.3Total 671 53184.3
Individual 95% CIs For MeanBased on Pooled StDev
Level N Mean StDev ----------+---------+---------+------ECHO 12 26.500 2.236 (--------*--------) HINDUPUR 154 23.968 7.777 (--*--) JANIF 170 21.641 10.222 (-*--) LAMMOGLI 161 16.497 7.513 (--*--) NUC 18 22.944 11.259 (-------*-------) ROWE 157 16.873 7.151 (--*-)
----------+---------+---------+------Pooled StDev = 8.322 20.0 25.0 30.0
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Other Data• ANOVA by Site• ANOVA by Weekday• ANOVA by Location (office, hospital, interp)• Regression Analysis• Descriptive Statistics
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56463626166
95% Confidence Interval for Mu
20.819.818.817.8
95% Confidence Interval for Median
Charge EntryVariable: DOS to
18.0000
8.5063
19.3333
Maximum3rd QuartileMedian1st QuartileMinimum
NKurtosisSkewnessVarianceStDevMean
P-Value:A-Squared:
19.0000
9.4632
20.6844
63.000025.000018.000014.0000 4.0000
6782.597511.1301480.2658 8.959120.0088
0.0008.160
95% Confidence Interval for Median
95% Confidence Interval for Sigma
95% Confidence Interval for Mu
Anderson-Darling Normality Test
Cardiovascular Consultants Overall Descriptive Statistics
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Similar Statistical Analysis• Transcription, delivery, coding and entry
took 11.5 days on the average• Dictate to transcribe took 5.4 days on the
average• Date of Service to dictate took 4.6 days on
the average
HEALTHY CHOICESHealthy Lives Heartland Health
Cardiology Office Non Invasive Charge Throughput
Cardiology Consultants: Non-Invasive Services Current State
H:\HOME\PASTEPLUS\CHARGE THROUGHPUT\Cardiology Non Invasive Charge Throughput.pdq
Patient services
rendered at HRMC
Hospital tech completes preliminary finding
report
Tech places form with needed
documentation in doctor interp box
Tech charges in HannaH for technical
component of test with interp Dr. identification
Tech completes manual log sheet with: Pt name,
date, Rm #, Interp & Ordering Doctor
Doctor interp & dictate findings
Secretary files dictated findings in
temp file
Transcribed dictation received
via auto-fax @ Heart Center
Secretary compares temp
file with transcribed
dictation
September 2002
TOSEchoStress EchoHolterEvent MonitorTreadmillEKG
M204 generates
auto report to clinic
Data entry checks
reports via HannaH
printer for correct Dr.
admit/dictate type of service
Does report match
correct Dr?
Data entry gives M204 report to Access Rep to
create EF
Data entry corrects M204 report with correct Doc name
Access Rep gives EF's & reports to Coder
Any coding changes?
Return to Physician for
correction
EF's entered by data entry
Does temp file match
Transcribed dictation?
Does Heart Center
Secretary find dictation?
Secretary faxes list of missing
reports to Clinic Access Rep
Does Access Rep
find transcribed
reports?
Access Rep send transcribed report to
Heart Center Secretary
Permanent report filed
No
Yes
Coder received codes & copies report
Original report to chart; copy with EF to data entry
Is report found?
Yes
No Refer to page one - Clinic Non-Value
Added Steps
Yes
Yes
No
Page 1 of 2
Page 2 od 2
Does AR find documentation in the transcription
log?
AR looks for documentation in clinic
chart
Does AR find in Clinic
chart?
AR faxes back to Heart Center
Secretary
No
No
Yes
Yes
AR checks HannaH
Did AR find documentation
in HannaH?
AR calls outsource
Does outsource
locate report?
Outsource sends copy to data entry clerk thru
normal process
No
Yes
AR continues to look for documentation
Is documentation
found?
No
Yes
Access Rep mades additional list for
doctor
Return temp file
copy to doctor
to dictate
No
Yes
(A)
(A)
NOTE: At future date EF is cancelled if documentation is not found
(B) (B)
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Similar Flow Charts• Cath lab charge throughput• Hospital charge throughput• Cardiology office other charge throughput
HEALTHY CHOICESHealthy Lives Heartland Health
Solution Matrix1. Review analysis data2. Incorporate Poka-yoke3. Brainstorm possibilities4. Select criteria & weight
to prioritze solutions5. Individual multi-vote6. Team validation of vote7. Assign resources 8. Combine solutions9. Test some solutions10. Implement quick fixes
1. Flowcharts, data, pareto.2. Change concepts.3. Say what you think.4. Impact on timeliness,
accuracy, efficiency and comprehensiveness.
5. High-medium-low.6. Subgroup team
meetings.7. Dr., Education, I/S, staff,
tools, capital, etc.8. Combine solutions for
action plan writing.9. Testing solution #24.10. Implemented
#1,3,15,16,22,43,58.
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25% 25% 25% 25%3 = High 3 = High 3 = High 3 = High
2 = Medium 2 = Medium 2 = Medium 2 = Medium
1 = Low 1 = Low 1 = Low 1 = Low
Solution by VenueImpact on Timeliness
Impact on Accuracy
Impact on Efficiency
Impact on (missed charges)
Comprehensiveness
MGP Charge ThroughputClinic Office Solutions
1Access Rep checks off office encounters on reconciliation report daily (same day). 14 7 14 11
2Physicians dictates the same day into outsource system (spell patient name, MRN, DOS). 21 21 21 21
3Separate work type numbers for each provider done thru software. 11 7 11 9
4Tech marks services on encounter form for any add-on test performed. 19 20 20 20
5
Access Rep looks for missing encounter forms the same day. If not found, access rep cancels encounter and creates a new one. Need to cancel as to not have duplicate charges, which cause reversals in AFM. 20 10 13 20
6 HIS Clerk prints dictated reports. 9 9 10 6
7HIS Clerk routes dictation to designated person (days kept together) 10 6 7 6
8Designated person matches encounter form to transcription documents. 20 21 20 20
9HIS Clerk or Access Rep looks for missing transcribed reports. 20 20 20 20
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Action PlansIndividuals assigned solution(s) to draft action
plan for team to agree with.• Action plan worksheet is tool of choice.
1. What is the action step to be taken?2. Who(team or non-team) is responsible for this
step?3. Method or how the step will be completed?4. Resources needed to successfully implement?5. Date the step is to be completed?
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Action Plans• By location of services
1. Office including office testing2. Hospital3. Cath lab4. Non-invasive lab5. Outreach clinics
• Includes steps for monitoring or measuring andhow the results are communicated
• Includes steps for education & training
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Transition• Monitoring action plans with:
– All the stake-holders– Administration– HR planning– Physicians and other providers– All the hospital departments– Public if necessary– Other as necessary– Revise action plans as necessary
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Evaluation• Results of the new implementations – what
variables, how collected and analyzed.• Process variance analysis including factors
by provider and site.• Six month during team, 1 year post team
results.• Identify need for post-implementation
teams.
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0 10 20 30 40
USLUSL
Process Capability Analysis for DOS to Entry
USLTargetLSLMeanSample NStDev (Within)StDev (Overall)
CpCPUCPLCpk
Cpm
PpPPUPPLPpk
PPM < LSLPPM > USLPPM Total
PPM < LSLPPM > USLPPM Total
PPM < LSLPPM > USLPPM Total
5.0000 * *
13.4269260
4.247355.39847
*-0.66
*-0.66
*
*-0.52
*-0.52
*1000000.001000000.00
* 976374.45 976374.45
* 940736.09 940736.09
Process Data
Potential (Within) Capability
Overall Capability Observed Performance Exp. "Within" Performance Exp. "Overall" Performance
Within
Overall
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One-way ANOVA: DOS to Entered versus Provider
Analysis of Variance for DOS to ESource DF SS MS F PProvider 3 3504.3 1168.1 74.22 0.000Error 256 4029.3 15.7Total 259 7533.6
Individual 95% CIs For MeanBased on Pooled StDev
Level N Mean StDev ---------+---------+---------+-------HINDUPUR 87 12.805 4.547 (--*-) JANIF 64 16.719 4.492 (--*--) LAMMOGLI 71 8.451 2.902 (--*--) ROWE 38 18.605 3.251 (--*---)
---------+---------+---------+-------Pooled StDev = 3.967 10.5 14.0 17.5
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Similar ANOVA• All the following ANOVAs were
statistically significant– Dictate to transcribed vs. provider– Transcription delivery vs. provider– Delivery, coding and entry vs. provider– DOS to dictate vs. provider
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9 15 21 27 33
95% Confidence Interval for Mu
12.6 13.1 13.6 14.1
95% Confidence Interval for Median
Variable: DOS to Entry
A-Squared:P-Value:
MeanStDevVarianceSkewnessKurtosisN
Minimum1st QuartileMedian3rd QuartileMaximum
12.7683
4.9661
12.7241
4.7910.000
13.4269 5.393329.08731.197082.75253
260
7.0000 8.000013.000017.000037.0000
14.0856
5.9014
13.2759
Anderson-Darling Normality Test
95% Confidence Interval for Mu
95% Confidence Interval for Sigma
95% Confidence Interval for Median
Cardiovascular Consultants Descriptive Statistics
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Results • DOS to dictated average 2.7 days• Dictate to transcribed average 0.8 days• Transcribed TAT average 1.5 days• Delivery coding and entry average 9.7 days
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Sigma Values & Yields• Physician Productivity
• Timely Charge Entry of 5 days from Date of Service– DOS to Entry = 33%– DOS to Dictate = 40%– Transcribed = 85.7%– Coding & Entry = 17.8%
• 1st pass accuracy of encounter form
• Comprehensive for services rendered
• Efficiency: Clerical FTE’s per 10,000 Work RVU’s
• Yield = 96.7% Sigma = 3.34
• Yield = 2.05% Sigma = (.54)
• Yield = 92.2% Sigma = 2.92
• Yield = 97.5% Sigma = 3.46
• 2.89 = 44th % MGMA
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Workout Teams• ICQC
– Baseline: 3rd Qtr FY02• 87.3 = 50th %
– 1st Qtr FY03• 90.2 = 71st %
– 2nd Qtr FY03• Not available
• Provider Documentation– Turnaround Time: Baseline
• DOS to Dictate = 4.57 days• Dictated to Transcribed = 5.43
– Transcription Cost: Baseline FY02• Total per month = $6,561• Per Work RVU = $1.49
– Turnaround Time: Jan 03’• DOS to Dictate = 2.70 days• Dictated to Transcribed = .78
– Transcription Cost: YTD FY03• Total per month = $6,409• Per Work RVU = $1.55
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Net revenue / Cost recovery• Target FY03
– $680,000• Baseline Opportunity
6 months– Gross Charges + 25%
• $1,152,666– Accrued Net Revenue
• $530,226 (46%)– Comprehensive Charges
• $46,888– Accuracy (ABN, W/O)
• $61,393 – Timely
• $30,000 Cash flow– Efficiency
• $51,033
• Total $611,259
• Results:July-Dec 2002 – Gross Charges Increase
• $1,051,548– Accrued Net Revenue
Increase to G/L• $488,970
– Comprehensive Charges• Included in Accrued Net
– Accuracy (Included in Accrued Net)
• $33,829– Timely
• $0– Efficiency
• ($28,788)• Transcription & Clerical cost
savings expected Jan - June
• Total $460,182
HEALTHY CHOICESHealthy Lives Heartland Health
Net revenue / Cost recovery• Target FY03
– $680,000• Baseline Opportunity
6 months– Gross Charges + 25%
• $1,152,666– Accrued Net Revenue
• $530,226 (46%)– Comprehensive Charges
• $46,888– Accuracy (ABN, W/O)
• $61,393 – Timely
• $30,000 Cash flow– Efficiency
• $51,033
• Total $611,259
• Results:July 02-June 03 – Gross Charges Increase
• $1,670,568– Accrued Net Revenue
Increase to G/L• $768,461
– Comprehensive Charges• Included in Accrued Net
– Accuracy (Included in Accrued Net)
• $48,940– Timely
• $0– Efficiency
• $6,216
• Total $774,677