Using Lean Six-Sigma Tools to create and implement a common way of doing things across an integrated health system.

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The Phoenix Project Integrating Effective
Disease Management Into Primary Care Using Lean
Six-Sigma Tools
John Oujiri, MD Cynthia Ferrara, MS St.
Marys/Duluth Clinic Health System
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St. Marys/Duluth Clinic Health System (SMDC)

• Integrated health system
• Main Campus in Duluth,MN with three neighborhood
  sites
• 16 regional clinics throughout northeast MN and
  northwest WI
• 400 physicians

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• SMDC clinics are located over 25,000 square miles
  and serve a population of nearly half a million
  people
• 18.7 people per square mile
• 11.4 of population below poverty level (2004)

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Goal of Phoenix Project
Develop a standard set of workflows for
delivering evidence-based care that provides a
consistent clinical experience for patients and a
consistent process for care teams. Differentiate
our organization to payers, employer groups, and
government agencies.
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• Phoenix Lean Process Road Map

• 8. Control Phase On-going
• Sustain and Continuous Improvement
• 7. Staged Implementation Pilot Sites 1-3 Feb
  08-July 08
• 6. Report to Sponsors November 2007
  
• 5. Midway Report and Feedback
  August 2007
• 4. Sponsor Update Frequent
• 3. Weekly Action Meetings Start June
  2007
• 2. 4-Day Breakthrough Work-out
  June 2007
• Pre-Launch Planning
  May 2007

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Cross-functional teams from pilot sites (3)
assembled to apply lean design concepts to core
processes and systems in four-day
event.Empowered to develop solutions/actions.C
ore Breakthrough Team Members Staff and
physicians from pilot sites and key leadership.

• 4-Day Breakthrough Work-Out

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Value Stream Mapping
Captures the current reality Defines value from
customer perspective Forms the basis for an
implementation plan
Demonstrates waste, gaps and major constraints in
care delivery Identifies value-added steps
needed
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Major Red Flags Identified

• Lack of consistency across clinics in key
• sub-processes, roles and workflows
• Under-utilization of EPIC (Electronic Health
  Record) capabilities and a variety of individual
  physician solutions rather than a system solution
• Daily mountains of rework by the most constrained
  resources in Primary Care
• Information Gaps at several critical points in
  the delivery of Primary Care. Waste identified
  during encounter and rooming process due to lack
  of any pre-visit planning
• Significant Patient Activation opportunity

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Four guiding principles developed to help move
from the current process to an effective and
efficient model of care delivery.
Do the right thing. Do it right
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Phoenix Guiding Principles
Practice to the full scope of licensure
abilities
Automate work That No Human Should Do
Create and implement a Common Way of Doing Things
across the Duluth Clinic system
Design Centralization into our process wherever
it makes sense
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Lean Strategies Applied

• Visual Management Use of simple signals and
  signs in EPIC
• Standardization Work gets done so that the
  outcomes are more predictable
• Mistake Proofing Building error prevention
  into the design of the process
• Constraints Analysis / Bottleneck Reduction
  Improving flow by designing to overcome
  resource constraints. Move work forward
• Automation Taking routine tracking tasks
  out of the hands of people and into EPIC

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Elements of the New DesignPre-Visit Planning

• Centralized, pre-visit planning takes place for
  every scheduled visit
• Standard process, questions and protocols
• Labs ordered per protocol
• Health Maintenance alerts
• Initial Med Review takes place before patient
  appointment

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Elements of the New DesignCheck-in and Rooming

• Lab First tasks are completed prior to rooming
• A standardized rooming process (i.e.
  socks/shoes off for diabetic visits, BP
  measurement, depression screening)
• Med Review by CA at rooming
• Load and pend Best Practice Alerts for physician
  order approval

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Elements of the New DesignPhysician/Credentialed
Practitioner

• Information needed for the encounter has already
  been prepped for provider
• Provider will
• Reconcile med list
• Update Problem List
• Make a follow-up appt plan with each visit
• Enter future orders
• Support patients behavior change efforts
• Enter patient instructions

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Elements of the New DesignPatient Activation

• Health risk, knowledge and activation assessment
• RN Coaching Model
• Disease coaching and care coordination is a
  value-added service that payers have been willing
  to reimburse
• Motivational Interviewing skills
• Use of enhanced take-home patient instructions
• Creation of a Disease Management Care Plan
• EPIC / MyHealth online tools allow patients to
  access their medical record, review labs, etc

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Elements of the New DesignCheck-Out

• 100 of patients are directed to check out
• Every patient receives an After Visit Summary
• Communicates what occurred during the visit
  Includes instructions and updated Med List
• Next appointment scheduled
• Future labs ordered, per provider and protocol

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Process Steps and Perceived Complexity
These additional up front process tasks represent
Prevention of process rework and delays on the
day of encounter
Appears to be more complexity in the front end
of process
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Control PhaseKey Performance MetricsBalanced
Scorecard/Strategy Map Measures

• Process
• of patients with
• Completed pre-visit planning
• Health Maintenance alerts satisfied
• Lab orders complete
• Medication list reviewed
• RN coaching appointment (per selection criteria)
• After Visit Summary, Med list and next appt
  scheduled

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• Clinical
• Optimal Diabetes Management 25
• Customer Service
• Achieve 10 increase in overall patient
  satisfaction
• Financial Physician and Staff Productivity
• RVUs/Provider FTE
• Direct Operating Margin
• Encounters per Support Staff FTE

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Feedback to Care Teams

• Routine reporting feedback loop
• Data is provided at physician,clinic and system
  level for all SMDC clinics
• Incorporates evidence-based guidelines in
  assessing quality performance
• Process and outcome measurement, evaluation and
  management
• Data is transparent within the health system

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Diabetes Optimal Management of Patients Meeting
All 7 MeasuresPhoenix Project Pilot Site
1June 07-July 08n556
Implementation Feb 08
() Includes A1C in last 6 months Blood
Pressure lt130/80 A1C lt7 Tobacco Free LDL in
last 12 months Anti-platelet use in patients
over 40 y/o LDL lt100 mg/dL.
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DC-Clinic CDiabetes ManagementJune 2007 June
2008n981
Feedback to Physicians and Staff Physician Level
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Implementation Feb 08
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Phoenix ProjectImpact on Disease Management

• Integration of population-based disease
  management into routine care
• Decrease in missed opportunities for lab work and
  increased of patients up-to-date (A1C, LDL,
  etc)
• Future appointments and labs scheduled before
  patient leaves the clinic, whenever possible
• Improved patient engagement in self-management
• RN Coach Alert fires within EHR for patients
  meeting criteria for referral
• Patients receive After Visit Summary that clearly
  communicates what occurred during their visit,
  including instructions and next steps
• Prepared proactive care team
• Lab results available at time of appt increase
  effectiveness of pt visit
• Intentional and focused efforts to enhance
  disease management has led to health plan
  collaboration and improved reimbursement structure

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Ongoing Challenges

• Change Management
• There is nothing more difficult to carry out,
  nor more doubtful of success, nor more dangerous
  to handle, than to initiate a new order of
  things. Machiavelli, The Prince, 1513
• Physician Engagement
• Clinical Inertia
• Unexplained Variance
• Reluctance in system to hold individuals
  accountable for implementation and results, i.e.
  culture of consequences
• No Net New
• Ensuring that efficiencies gained allow for value
  added activities without increase in resources
• Value must be defined by external customer
  (patients and families) rather than internal
  (staff, physician, payers)

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Lessons Learned

• Implementing lean thinking in a traditional
  health care culture is not for the faint of
  heart (IHI)
• Communication is essential
• Do not underestimate the response to change in
  status quo
• The vocal, unhappy minority cannot steer the ship
• Senior leadership support is invaluable
• Involve patients in planning process
• Not a quick fix
• Improvement to metrics will take time
• Will require sustained commitment
• Clear definition of roles and responsibilities
  will help project move forward
• You get what you expect and you deserve what you
  tolerate

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Questions ?
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