Lean Process Engineering in Small Practices

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Lean Process Engineering in Small Practices

• Masspro
• Joseph Holtschlag, Manager, DOQ-IT
• Harvard Quality Colloquium
• Aug 20, 2007

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Session Overview

• Small practices dont need workflow redesign as
  much as they need management redesign
• Addressing management and culture issues will
  achieve Lean goals
• Small practices can make dramatic changes faster
  than larger groups, creating patient-centered,
  efficient, effective care providers

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Masspro

• Federally designated Quality Improvement
  Organization for Massachusetts
• Quality improvement projects in home health,
  ambulatory, and hospital settings
• DOQ-IT Project
• Funded by Centers for Medicaid and Medicare
  Services in April 2004
• Established to support and assist the adoption
  and use of EHRs in small and medium-sized primary
  care practices
• Gained experience by working with 318 practices
  across MA

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What is a Small Practice?

• 1-3 providers (MD, PA, NP)
• 3-10 additional staff
• Administrative support
• Medical assistants
• Some support from hospital
• Membership in IPA/PHO
• Characteristics
• Personal relationships with patients
• Affiliations tend to be loose
• Focused on quality of visit
• Under-resourced

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Current State of Small Practices

• Wasteful, leaky
• Under-utilized people
• Set job definitions
• Little empowerment, trust, incentive
• Waiting
• Wait until work arrives
• Interruptions
• Over-processing
• Double checks on many tasks
• Unnecessary movement
• Looking for information
• Paper storage, routing of information

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Current State of Small Practices
Care that is Efficient Effective Patient-centered
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Small Practices and Lean Methodology

• Small practices challenge
• the definition and application of Lean
• If Lean means
• process redesign committee
• formal documentation
• staff trained in Lean methodology
• Then Lean will not find a willing audience
• If Lean means
• eliminating waste
• utilizing staff more effectively
• reducing over-processing
• decreasing waiting and interruptions
• Then small practices are interested

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How to Change
Catapult of EHR
Project Leadership
Teams
Measurement

• Combine to achieve Lean goals
• eliminate waste
• utilize staff more effectively
• reduce over-processing
• decrease waiting and interruptions

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Current State of Small Practices

• EHR is the catalyst for change
• The nature of paper is wasteful
• No matter how hard the practice works in paper,
  services and operations will never be coordinated
• Compelling quality and efficiency arguments have
  been made for electronic health records (EHR)
• Incentives for adoption
• Successful installation requires improvements in
  operations and management

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Empower Through Leadership

• Leadership
• Develop someone who can set a mission for the
  practice
• Physicians lead changes, develop clinical vision
• Office manager responsible for operations,
  finance
• Give practice tools to make it happen
• Guide practice through the project charter
  development
• Provide structure for staff meetings
• Develop standards for management
• Educate on EHR project management
• Show decision points
• Expand possibilities
• Make a case for benefits of project management

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Empower Through Teams

• Teams
• Change the preconceptions of what people can do
• Cross-train tasks
• Expand clinically-significant roles
• Fit the people to the job responsibilities
• Engender trust through training
• Physician leadership in clinically significant
  training
• Develop subject matter experts to train fellow
  staff members
• Distribute responsibility
• Ask individuals to tackle problems in their area
• Give them the power to make changes to their job
  and the responsibility to make changes work

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Empower Through Measurement

• Measurement
• Practice leaders needs to know that
• Standards of care are being met
• Expanded responsibilities are meeting goals
• Judgments and decisions are objective
• Cant manage what you cant measure
• Matching improvement efforts to objective
  information
• Quality
• Operational
• Financial
• Patient satisfaction
• Final step in improving practice communications

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Results

• Waste becomes everyones responsibility
• Efficient movement
• EHR reduces movement
• Staff empowered to find better solutions
• Using staff to potential
• Healthcare providers ? Leaders, managers, mentors
• Clinical support ? Patient care team
• Secretaries ? Customer relations
• Less waiting and interruptions
• Better understanding of responsibilities
• More cross-training
• Proactive, predictive

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Session Conclusions

• Addressing the management and culture issues of
  small practices will achieve Lean goals
• eliminating waste
• utilizing staff more effectively
• reducing over-processing
• decrease waiting and interruptions
• High velocity of change in small practices leads
  to rapid improvements in quality and efficiency
• Communication is fast
• Dynamic nature of EHR makes continuous change a
  way of life
• Lean practice allows quality and efficiency
  improvements without bureaucratic impediments
• Small practices are ideally suited to delivering
  patient-centered, efficient, effective care

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Questions?

• Joseph Holtschlag
• Manager, DOQ-IT
• Jholtschlag_at_maqio.sdps.org
• [phone]