Problem Solving to Improve & Sustain Business Outcomes

Jennifer Goldstein MD FACP

Jennifer Nichols, MAC

December 5, 2019

Objectives

• Describe why Lean is important

• Demonstrate support and engagement in leading a culture of continuous improvement that utilizes disciplined processes

• Recognize the principles of the Lean improvement methodology

• Apply the tools of Process Improvement and Lean to deliver to your customers/patients and work areas

Q: What is the Operational Excellence Program Office?

A: The Operational Excellence Program Office (OpEx) is…

A team of staff members, with continuous/process improvement knowledge and expertise, who are focused on:• Supporting leaders to become operationally

excellent, drive the organization to be highly reliable and efficiently utilize resources

• Partnering to improve the work environment for staff while building their skill and knowledge base of continuous improvement

• Empowering employees in every day problem solving to improve access to our services and enhance patient experience

• Developing a culture of learning and experimentation to continuously improve

Q: What is Operational Excellence?

A: Operational Excellence is…A workplace where problem-solving, teamwork, and leadership results in the ongoing improvement in an organization.

The process involves:• focusing on customers• keeping the employees positive and empowered to improve their work

environment• continually increasing the value of the care provided in the workplace

A methodology used to continuously improve is lean

Q: What is Lean?

A: Lean is a continuous improvement methodology that maximizes the value to

the customer while minimizing waste

Definition of Lean

• Relentless pursuit of identifying and eliminating waste from a process

– Also known as non-value add activities

– Defined by the customer (ex. patient)

– Waste is also known as Muda

• Improving flow, creating more value for customers and eliminating waste

• Building quality into processes and systems

• Finding low-cost, reliable alternatives to expensive new technology

• Creating the best processes and practices

• Building a culture for learning and practicing continuous improvement

Q: Where did lean originate?

A: Not Healthcare

Airline Pharmaceuticals Nuclear Power

Automotive

Also used in many other industries!

Lean in our daily lives….

http://www.leanreflections.com/2012/06/lean-thinking-applied-to-daily-life.html

Turn hangers in your closet away from you to indicate

which clothes you don’t wear

Use shadow boards to make it obvious when one of your

tools is missing

Store like items together to save

time and money by keeping them

visible

Keep items where they are likely to be used. In this case,

near the bathroom sink

History of Lean Production System

Model T Ford

Assembly Line

Inspired principle of

“flow”

American

Grocery Store

Pull system – pull from the

front, replenish from the

back to maximize freshness

of items

Indianapolis 500

Car Race

Reduce wasteful

downtime with rapid

changeover

Lean and Healthcare

Virginia Mason Intermountain Stanford University of Michigan

While lean is less familiar in the healthcare

setting, there are prominent examples of

successful lean health systems since the

early 2000’s which are developing into more

highly reliable organizations

Lean and Healthcare

Virginia Mason Intermountain Stanford University of Michigan

Penn State HealthSince 2013

While lean is less familiar in the healthcare

setting, there are prominent examples of

successful health systems which operate as

high reliability organizations

What Lean is NOT

Disorder

UnstructuredSolely a leadership decision

“Cookbook Medicine”

Directionless

PD

SA

Occ

urr

ence

Tr

acke

r

Op

po

rtu

nit

y Ti

cket

Dai

ly H

ud

dle

Lean Tools

What Lean ISDiscipline Principles

People

A Disciplined Approach to Continuous Improvement

Empowerment

Engagement

Tools

Livi

ng

Pare

to

Value, Flow, Waste, Pull and Pursuit of Perfection

Value

Flow

Waste

Pull

Pursuit of Perfection

Who is your customer? How

does the customer value

your service

Is the process predictable and

reliable? Is work batched, are

there delays?

Is the service available at the

demand of the customer? How

do you know?

Intentional daily practice to

never stop learning and

practicing continuous

improvement.

What are the opportunities

to improve by removing,

redundancy, rework, and

non value added tasks?

Daily Huddle: Team or cross-functional group meetings

focusing on process status and identification of challenges

To prepare employees for their

day, the components of the

huddle are dependent on the

needs of the unit (Examples:

schedule, volumes, barriers)

Q: What are components of the daily huddle?

A: Daily Huddle Components are…

1. Situational AwarenessWhat’s going on around us?Ex. 3 call offs today

2. Operational ReadinessHow will we deal with it?Ex. 1 staff from float pool

3. EscalationWho do I need to get involved?Ex. Escalation to Daily Safety Brief

Huddle Board

PDSA Overview

Plan: Identify your problem

Do: Test potential solutions

Study: Study results

Act: Continue experimentation

until there is a solution

PDSA is simple process

improvement tool. The

acronym stands for:

P = Plan

D = Do

S = Study

A = Act

Q: What are the main process steps in Lean Problem Solving?

PDSA Overview

Step #1: What is the problem?

Why is there a problem?

Plan: Identify your problem

Do: Test potential solutions

Study: Study results

Act: Continue experimentation

until there is a solution

Plan, Do, Study, Act Overview

Plan: Identify your problem

Do: Test potential solutions

Study: Study results

Act: Continue experimentation

until there is a solution

Step #2:What are the

obstacles?

Develop solutions and experiment to

overcome identified obstacles

Plan, Do, Study, Act Overview

Step #3:Review the

test, evaluate the results

What did you learn?

Plan: Identify your problem

Do: Test potential solutions

Study: Study results

Act: Continue experimentation

until there is a solution

Plan, Do, Study, Act Overview

Plan: Identify your problem

Do: Test potential solutions

Study: Study results

Act: Continue experimentation

until there is a solution

Step #4;Did it work? Continue

Did it fail?Plan to try something

else

Start cycle over

Improvement Opportunity TicketFr

on

t

Bac

k

Exercise

• Using the opportunity tickets on the table, brainstorm some opportunities for improvement in your workplace

Is there a problem?

An occurrence tracker helps to determine how many times the issue occurred today, to understand the extent of the problem

All employees collect data on daily basis

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1

0

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

1 2 3 4 5 6

7 8 9 10 11 12

Occ

urr

en

ce

Day of the Month

Month Monthly Progress Toward Goal

J F M A M DJ A S O N

Goal:

Department:Occurrence Tracker

J

WHY there is a problem?

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# O

ccu

rren

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Reason for Fallout

Dept: Start Date:

A living pareto helps to identify the causes of the problem

All employees collect data on daily basis

Test your knowledge – Match Game

A. PDSA

B. Huddle

C. Operational Excellence

D. Lean

E. Living Pareto

F. Opportunity Ticket

G. Occurrence Tracker

___ Continuous improvement methodology that

maximizes the value to the customer while

minimizing waste

___ Simple process improvement tool, which

stands for plan, do, study, act

___ A workplace where problem-solving, teamwork, and

leadership results in the ongoing improvement in an

organization

___ Team or cross-functional group meetings focusing

on process status and identification of challenges

___ Used to determine how many times the issue

happened today, to understand the extent of the

problem

___ Used to identify the causes of the problem

___ Form used to identify new ideas to work on a

process issue

APPLYING LEAN IN HEALTHCAREMANAGEMENT

Authorization Task Force

Jennifer Goldstein, MD FACPMatt Hoeger, MBA,CHC

Lauren Pond, MS, BSN, RN, CCM, CMACVirginia Robbins, MPS, CHAM

Background

• Denied Insurance claims related to authorizations lead to – Patient dissatisfaction

– Provider dissatisfaction

– Significant rework and cost

– Delay in Patient Care

• HMC Revenue Cycle identified avoidable denials as a leading indicator of potential lost revenue

Taskforce Purpose & Goal

• Create process maps of current state authorizations (pre, concurrent, post)

• Analyze data to determine two main areas of improvement opportunity

• Identify tactics to improve authorizations in the two areas

• Create scorecard for these two areas

What is a Value Stream Map?

• A graphical map of the steps that occur from the specific request for a product or service to the delivery of that product of service

• It illustrates the flow of activities

• Gives the viewer the ability to see and improve the flow of the whole line of activities and identify opportunities to eliminate waste

VSM

• View from 10,000 feet

• Activities are recognized as value added or non-value added

• Identifies WHERE there are areas of inconsistency

• Springboard for a future state map

Current State Map

• The first iteration of the map should show the path of the product or service traveling through the stream

• Gives the observer an objective look at how the work flows now, faults in the flow, and can be used as a springboard to redesign the faults or barriers

Phase 1 – Current State VSAInpatient and outpatient elective procedures within the hospital

In Scope

• Authorization of hospital claims

• Elective procedures– Inpatients elective procedures

– Out patient elective procedure done at the hospital

Out of Scope

• Professional claims

• Pharmacy claims

• Radiology claims – imaging and infusion

• Out patient procedure not done in the hospital complex

Areas of Review

• Scheduling Process

• Precertification PPAS Process

• Precertification Denials Process

• Concurrent Authorization Process

• Claims Coding Process

• Billing Process

• Appeals Process

Ordering ProviderMOA

Surgery SchedulerService APP

Pre-Cert Associate

Scheduling

Preauthorization Nurses 3FT, 2 PT

Ordering ProviderInsurance Company

Clinic Staff

MOAS and Scheduler

Pre-Cert DenialsPPAS Insurance

Verification StaffRegistration StaffUM Nurses – 19UM Support – 1

UM Providers 1 FT, 2 PT

Executive Health Resources

Concurrent Auth

CodersClinic StaffProviders

Coding Appeal

Preauthorization Nurses 3 FT, 2 PT

Insurance CompanyClinic Staff

Authorization

Precertification- Virginia Robbins UM-Jen Goldstein, Lauren Pond Coding/Billing/Reimbursement- Matt Hoeger

Authorization Process – Elective Inpatient and Outpatient Procedures (Excluding Infusion, Radiology)

50-85m 28-163m

15.10 – 19.18 days

92-152m

.06 -14.34days

110-245m

1.19- 3.32days

20-55m

16.23d -35.51 days

0- 41min

3.04 – 11.11 days

Totals

LT: 7200m (15d) – 100,800 m 210d

PT: 78 – 906m

Efficiency Rate:1.08% - .89%

VA% (VA/NVA): 12.81% - 25.5% ( only include: Sched + Auth)

(C&A) Ratio: 38.5% (only include: Sched + Auth)

Appeals Spec 1, Appeals Nurse .2,

PFS (multiple teams), UM Nurse

Executive Health Resources

PT: 71 - 165 mins

LT: 16,391 (34d) – 38,100 (79.4d)

VA 0

NVA 0

%VA 0

C&A % 0

Efficiency Rate: .4% - .43%

71 – 165m

19 – 49.09 days

BillersCoders

Clinic Staff

Insurance Company

Billing

PT: 50-85m

LT: 7,250m (15.10d) – 9,205m (19.18d)

VA: 10-40m

NVA: 40-45m

%VA:25-47%

C&A % : 50%

Efficiency Rate: 0.69% - 0.92%

PT: 28 - 163m

LT: 28m (0.06d) – 6,883m (14.34d)

NVA: 27-177m

%VA: .62% - 4%

C&A % : 77.75%

Efficiency Rate: 2.37% - 100%

PT: 92-152m

LT: 572m (1.19d)- 1,592m (3.32d)

VA: 0

NVA: 0

%VA: 0

C&A % 0%

Efficiency Rate: 9.55%- 16.08%

PT: 20-55m

LT: 1,460m (3.04d) – 5,335m (11.11d)

VA: 0

NVA: 20-55m

%VA: 0%

C&A %: 75%

Efficiency Rate: 1.03% - 1.37%

PT: (Automatic) 0-41m

LT: 9,120m (19d) – 23,520m (49.09d)

VA: 0

NVA: 41m

%VA: 0%

C&A %: 75%

Efficiency Rate: 0% - 0.17%

Insurers

Cerner Scheduling

Power Chart

SurgiNet

Cerner Care Mgmt

Encoder

N-Thrive

Midas Rev Cycle

App Rev

Provider

Scheduling Card

Fax/e-FaxEmail Paper

E-msgPhone

HIS

PT: 110-245m

LT: 7,790m (16.23d) – 16,565m (35.51d) – 8h day

VA: 0

NVA:110-245m

%VA: 0%

C&A %: 95.6%)

Efficiency Rate: 1.41% - 1.48% - 8h day

34 – 79.4days

HMC Impact• As we review the pain points for each sub-process, pain

points were identified that Hershey Medical Center can impact

• Adding the HMC controllable pain points from each sub-process together creates the rate of potential impact

• 62 of 77 Pain Points = 81% Impact Rate under HMC span of control

• Data on complete and accurate on the first pass only 35% in the first 2 tasks

• Email used as work around due to the inability of our integrated system to communicate across modules

• Success rate of securing authorizations is 98% in spite of this flows indicating significant rework

Recommendation: Focus on Registration and Scheduling

• Medical Group leadership to partner with Hospital leadership as Executive Sponsors

• Medical Group Task Force leadership to partner with Authorization Task Force

• Recommend looking at scheduling flows and practices:

• General Peds, Peds Specialties, Peds surgeries

• Neurosurgery for adults

Impact to Revenue Cycle• 403,872 encounters for in for entire HMC

book of business where authorizations are required

• Complete and accurate ratio of 38.5% applied to 403,872 encounters is 155,491 that are completed and accurate the first time, and 248,381 encounters that required additional work.

• Initial denial of 6,336 hospital claims for no authorization

Questions/Comments??