Transcript Demand + Capacity = Outcomes

Redesign Boot Camp
Sample Content
January, 2011
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© 2011 HOUCK & ASSOCIATES, INC
Sue Houck
How Does Practice Redesign
Relate Success As A Patient
Centered Medical Home?
Despite PCMH NCQA recognition, primary care
remains under-resourced and inefficient with low
reimbursement rates. How we do things and use
resources was never intentionally designed. Until
we examine and “unfreeze” outmoded ways of
doing things we’ll never achieve the infrastructure
needed to sustain Patient Centered Medical
Homes.
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The Care Equation
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Demand + Capacity = Outcomes
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What Is Capacity
WHAT YOU DO
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To provide care-your processes e.g. rooming patients, refills, office visits, appointments, phone
messaging, phone advice
WHAT YOU HAVE
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To provide care-your resources e.g. physicians, staff, building, equipment, supplies, time,
relationships
WHAT YOU BELIEVE
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What you value. The stated and unstated agreements among physicians, managers, staff and
patients. Expected behaviors and norms. How decisions are made, who does what tasks
Which is easier to change?
Which is more expensive to change?
Does one have more impact than the others?
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The Changing Productivity Model
Old: Focus on visits as the measure of productivity
New :
PCMH & Accountable Care Organizations
Focus on panel size and population served as the measure
of productivity
How could PMPM payments in addition to fee-for-service impact the
changing productivity model?
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Why Improve
”When I look at the meeting
minutes, they never change
from year to year. We’re
always dealing with the same
unsolved problems.”
Medical Director, California
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Key Issues
For many physicians, changing to the
patient centered medical home requires
transformation at the personal level, as
practices must move from a physician
centric model to a team-centered and
relationship centered approach.
Source: Leading change to promote innovation. Christine Johnson, TransforMED
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What Patients Want
Patients are most satisfied with medical visits in which they
talk about their specific treatment, are examined, and receive
health education. There is a negative relationship with time
spent on history taking.
The Influence of Physician Practice Behaviors On Patient Satisfaction. Fam Med. 1993 Jan;25(1):17-20.Robbins, JA,
Bertakis, KD, Helms, LJ, Azri, R, Callahan, EJ, Creten, DA
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Remember
Values trump resources and processes every time. If you
a add new resource (e.g. midlevel provider) or change
a process (e.g. prescription refill protocols) and it isn’t
consistent with the core values of physician leaders, the
change won’t last.
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Site Visit Questionnaire
•Collects key data and information that provides
useful overview of practice operations & PCMH
readiness
•If collected before initial visit, data enables you
to “hit the ground running”
•TIP: Scheduling a call to discuss the
questionnaire with key physician or manager
before you send it often yields better data
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Improving the Invisible
“On any given day, office staff can be observed
busily completing various work processes, but
it’s not always clear exactly where those
processes begin and end. In fact, much of the
work isn’t tangible or easy to see. To some
extent improving care is like improving the
invisible.”
What Works, Effective Tools & Case Studies To Improve Clinical Office Practice,
Houck, S. 2004.
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The Care Equation
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Demand + Capacity = Outcomes
Resources
Processes
Values
The work that
comes in
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Operational
Financial
Satisfaction
Meet Frank Sweet
Ex-rock star Frank Sweet is a
patient of Dr. Ben Francisco’s.
He has Type II Diabetes,
hypertension, CAD and a
strong independent streak
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The Care Matrix
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Action
Physicians
Information
NonPhysician
Staff
Decision Making
Patients
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Daily Work Processes
Refill medications (12)
Send e-mail messages (17)
Review consultant reports (14)
Demand
Office visits (18)
Review results of lab (20) and imaging (11)
Make phone calls (24)
Baron, R. The New England Journal of Medicine. (April 29, 2010) What’s
keeping us so busy in primary care? 362:17, 1632-1636.
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Outcomes
Seeing Where To Improve
Efficient Use of Resources
Refill medications
Send e-mail messages
Review and document consultant reports
Office visits
Review and document lab and imaging results
Phone calls
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1. Match enough of the right
resource with the need
2. Do today’s work today vs.
push into the future
Lean Process Redesign
Demand
1.
2.
3.
4.
5.
6.
Map steps in value streams
Outcomes
How much variation
Is there duplication of effort
Where are there hand-offs & delays
How long to complete
Can any steps be delegated, deleted,
or automated
7. What problems do staff see with the
process
8. Does anyone own the process, if so
will that help or hinder change
Outcomes
See also: “Mapping Your Way to Leaner Workflows” Practice Management News, California Academy of Family
Physicians. January 2009, Houck. S.
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Walking into a
practice how
might you see
and hear
“impacted”
processes?
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Describe Process
Inefficiencies at Your Practices
Vs.
1. Minimize number and
complexity of steps
2. Remove non-value added waits
during and between steps
3. Synchronize key steps to
optimize overall flow (e.g.
appointment times)
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How Would You Improve
This Process ?
Refill Process
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Patient notices he needs refill
Patient decides to call office to request refill
Patient calls office and refill request message is taken
Request is sent to nurse
Nurse reviews request (≤3 hours)
Nurse reviews EHR
Nurse sends message to MD
MD reviews EHR
MD authorizes refill (≤36 hours)
MD sends EHR and message back to nurse
Nurse reviews physician documentation and calls in refill (≤12 hours)
Nurse calls patient to notify that refill has been called to pharmacy
Nurse documents refill in EHR
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Why Delegate?
A 2005 study estimated it would take 825 hours per year to
provide care as advised in national guidelines for wellcontrolled patients with the top 10 chronic diseases for a
panel of 2,500 patients. That’s 3.5 hours a day. When
requirements for uncontrolled disease were factored in,
time demands more than tripled.
(T. Ostbye, K. Yarnall, K. Krause, K. Pollack, M. Gradison, Annals of Family Medicine. May/June
2005; 8:3.)
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Space Matters
Fourteen inches of glass
atop 4 foot partitions
facilitate visual access to
work flow. In addition,
conversations now stay
within the pod as opposed
to “lean-over” and hallway
conversations.
Reception and
appointment staff are colocated close to clinical
staff for easy
communication and
teamwork
Clinica Campesina, Denver, CO
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Exam rooms (3 per provider)
surround clinical staff work
area enabling real-time visual
access to work and patient
flow.
Open check-in areas are
visually accessible to
clinical staff; having no
sliding glass doors or high
counters means no barrier
for patients
Teamwork Matters
Better teamwork is associated with better
processes of care for patients with diabetes. One
study also found that teams improve continuity of
care, access, and patient satisfaction.
Campbell, S., Hann, M., Burns, C., Oliver, D., Thapar, A., Mead, N., Safran, D.,
Roland, M., 2001
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Case Study
Current State
Vs.
Better
Vs.
Best?
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Vary Ways To Access Care
4
Physician
office
visits
Self-care
Vs.
Mid-level visit
Group visit
Physician office visit
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Is Non-Visit Care Really
An Option?
Email and phone care have eliminated a substantial
number of total face-to-face visits for our patients -- not just
visits to our practice but also visits to urgent care and
emergency departments, and to specialists. Approximately
40% of our contacts with patients are done over the
telephone, another 40% by email, and 20% via office
visits. Effective care is still delivered, it is just done so
through mechanisms in addition to face-to-face visits.
Sidebar: GreenField Health System: Moving Intermittent Office Visits Toward
Continuous Communication http://www.medscape.com/viewarticle/490144_13
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Balancing
Capacity &
Demand
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Match Resources With Predictable
Variations in Demand
35.0%
30.0%
25.0%
Daily % of wkly demand
log 1
20.0%
Daily % of wkly MD
capacity
15.0%
10.0%
5.0%
0.0%
Mon
Tues
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Wed
Thurs
Fri
How Do “Mismatches” Between
Capacity & Demand Show Up?
Demand
•Number of Patients 2,000
•Number, frequency, & timing
of requests for visit, refill,
advice, results & referral
•Demographic,
socioeconomic & cultural
characteristics
•Information, decision
making, and self-treatment
skills of patients
+
Capacity
•Support staff ratios, 4.7 total/FTE MD,
1.7 clinical
-Provider & staff work days/yr,
hrs/day
-Daily, weekly, & seasonal
variation in staffing
-Staff turnover rates
•Physical plant: exam rooms/provider,
layout, equipment
•Workflow efficiency
•Leadership & culture
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Measuring Demand
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Case Study
We Varywel Family Medicine
1 FTE MD
Demand
+
Capacity
•3.33 total support staff,
including 1 clinical
support/FTE MD
2,100 Patients
•2 exam rooms/provider
•Provider session staffing=
M=1/0, T=1/1, W=1/1,
Th=1/1, Fr=1/1
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Outcomes
•Revs=$69.00/visit
•4,898 office visits
•Cycle time=76 min.
•No-show rate=15%
Approach
“I’d like to have more time
with my family”
“In addition to keeping up with
the work I’d like to increase
my income by 7%.”
“I’d like to know I’ve really
improved care for my patients
with asthma.”
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In the process of making
recommendations,
explore the impact of both
“where it hurts” as well as
benefits of achieving what
matters most.
Sample questions include:
“What is the impact of
having your income
decline?” or “What would
being able to keep up with
the work do for you?”
Approach
Observe how physicians and staff respond
to your observations and recommendations.
Advise them that you’ll make lots of
suggestions to see what works for them.
If a suggestion such as initiating group visits
receives a positive response, send an article
or link to a website with more information.
Then follow-up to see whether interested
physician/s would like to proceed.
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Role of Leadership
• Emphasize importance to all staff,
hold accountable
• Communicate support
• Visibly celebrate gains
• Permission to “break up” old
ways
• Willing to act to remove barriers
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Collect & Post Data
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PDSA Cycles
PDSA Cycle Tool
Cycle _____________________________
Date begun______________________________
Plan
What‘s your objective, what question/s would you like to answer and what do you predict will happen? Who will do
what when and where and what data will you collect.
Do
Carry out your plan and document what you observe including observations and any problems
Study
Analyze your data
Compare the data to your predictions and briefly state what you learned
Act
What changes are you going to make?
What will happen in the next cycle?
Adapted from: Langley, G., Nolan, K. Nolan, T., Norman, C., Provost, L., The Improvement Guide. San Francisco:Jossey-Bass, 1996.
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Beyond Carrots &
Sticks
• Share data regarding quality measures in ways
that will get noticed and promote competition
among practices, e.g. in public areas of practices,
on websites, at meetings etc.
• Use your power as conveners to celebrate
practices that are making progress
• Make sure the data is un-blinded
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Traditional Care Vs.
PCMH
Rigid roles for physicians and staff
Blurring of traditional roles
Patient creates demand, providers
and staff bring capacity
Patient creates demand and
capacity
Physician tasks include repeating
instructions, minor illness and well
care
Physicians and staff function at
highest level of skill and licensure
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Traditional Care Vs.
PCMH
One-on-one physician office
visits
Individual, mid-level, self-care,
phone, electronic. and group visits
Schedule drives daily work
Care intentionally planned around
needs of a population of patients
Everyone has a job to do
Everyone’s job is to work as a
team to improve health of
population of patients
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Next Steps
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