Working Smarter, Not Harder
Brett Williamson, LSW, MBA
Program Director
Objectives
1.
2.
3.
4.
Participants will have a basic understanding A3
problem solving process and its application to
healthcare services and their own workplace.
Participants will learn about specific techniques
to perform root cause analysis.
Participants will be able to identify processes
within their programs where the application of
lean methodologies may reduce waste.
Participants will be able to apply organization
change strategies to promote lean
implementation.
Why is going Lean so important?
■
Rising Healthcare Costs.
■ Organizational expenses rising 3-5% annually.
■ Behavioral Healthcare Reimbursement not keeping
up with expenses.
■ Meeting certain regulations can be labor intensive
and lack an adequate reimbursement structure.
■ Organizations are being forced to do more with less.
■ Pay-for-performance standards will force
organizations to reduce errors.
Lean = Elimination of Waste (muda)
■
8 categories of waste
1.
2.
3.
4.
5.
6.
7.
8.
Overproduction
Excessive Inventory
Defects
Non-value added processing
Waiting
Underutilized people
Excess Motion
Transportation
There is nothing so useless as doing efficiently
that which should not be done at all.
~Peter F. Drucker
Nothing stops an organization faster than
people who believe that the way you worked
yesterday is the best way to work tomorrow.
~Jon Madonna
“ Lean solutions involve looking at processes, breaking
them down into parts, and eliminating waste.”
Establishing lean processes through the elimination
of waste improves efficiency, productivity, employees
satisfaction and patient satisfaction.
-Carol Berczuk, The Lean Hospital, 2008
Change is the Key
Every organization has an institutional culture.
That same culture can lead to complacency.
An attitude of “we have always done it this way”
is sure to lead to problems.
Organizations must develop a Culture of
Leadership where leadership is defined as
the ability to cope with change.
Leaders are visionaries with a
poorly developed sense of fear
and no concept of the odds
against them.
~Robert Jarvik
Our only security is our ability to
change.
~John Lilly
Traditional vs. Lean Culture
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Traditional
Functional silos
Managers Direct
Benchmark to justify
Blame people
Rewards: individual
Supplier is the enemy
Guard information
Volume lowers cost
Internal Focus
Expert Driven
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Lean
Interdisciplinary Teams
Managers teach/enable
Seek ultimate performance, absence of
waste
Root Cause Analysis
Reward: Group sharing
Supplier is the ally
Share Information
Removing waste lowers cost
Customer focus
Process Driven
Institute of Healthcare Improvement, Going Lean in Health Care. Innovation Series 2005
If you want to truly understand
something, try to change it.
~Kurt Lewin
Organizational Change
■
Kotter’s 8-Step Change Model
1. Create Urgency
A. Identify potential threats, develop scenarios
showing what could happen in the future.
B. Examine opportunities for potential
exploitation.
Neither a wise man nor a brave man
lies down on the tracks of history to
wait for the train of the future to run
over him.
~Dwight D. Eisenhower
8 Step Change Model
2.
Form a Powerful Coalition
A. Convince people that change is
necessary.
B. Bring together influential people.
C. The team needs to continue to build
urgency and momentum around the
need to change.
8 Step Change Model
3.
Create a Vision for Change
A. Identify the values central to the change.
B. Develop a clear and concise summary
that describes how you see the future.
C. Create a strategy to execute the vision.
A leader has the vision and conviction
that a dream can be achieved. He
inspires the power and energy to get it
done.”
— Ralph Lauren
8 Step Change Model
4.
Communicate the Vision
A. Talk about the vision at every
opportunity.
B. Remember what you do is much more
important than what you say.
C. Lead by example
The difference between the right word
and the almost right word is the
difference between lightning and the
lightning bug.
~Mark Twain
The less people know, the more they yell.
~Seth Godin
8 Step Change Model
5.
Remove Obstacles
A. Identify change leaders in you
organization.
B. Make sure your organizational structure
is in line with your vision.
C. Recognize and Reward individual for
leading the change.
D. Act quickly to remove barriers.
8 Step Change Model
6.
Create Short-Term Wins
A. Create short-term targets, success
motivates.
B. Again, reward individual and/or groups
for meeting the targets.
8 Step Change Model
7.
Build on the Change
1. Analyze each success to determine
reasons for success and areas for
improvement.
2. Set goals that build on the momentum.
8 Step Change Model
8.
Anchor the Changes in Corporate
Culture
A. Build the culture of change into the hiring
process.
B. Recognize key leaders of change.
Resistance to Change
■
■
Any Organizational Change will
encounter some resistance.
Kotter and Schlesinger (2008) stress the
importance of recognizing the 4
common reasons people resist change.
Kotter and Schlesinger, Choosing Strategeies for Change
When you are through changing, you
are through.
~Bruce Barton
Failure is not fatal, but failure to
change might be.
~ John Wooden
4 Reasons for Resisting Change
1.
2.
Parochial Self-interest: people resist
change because they think they will lose
something of value. They will focus on their
own best interest not the best interest of the
total organization.
Misunderstanding and Lack of Trust:
when individuals do not understand the
implications of the change, they may
perceive that they have more to lose than
they will gain.
Kotter and Schlesinger, Choosing Strategeies for Change
4 Reasons for Resisting Change
3.
4.
Different Assessments: people may
assess the situation differently than those
leading the change and see more costs than
benefits for both themselves and the
company.
Low Tolerance For Change: people fear
that they will not be able to develop new
skills and behaviors that will be required as
a result of the change.
Kotter and Schlesinger, Choosing Strategeies for Change
Change is hard because people
overestimate the value of what they
have—and underestimate the value of
what they may gain by giving that up.
~James Belasco and Ralph Stayer
Flight of the Buffalo (1994)
Lean Management Defined
■
■
Lean management utilizes the
systematic elimination of waste from all
aspects of an organization's operations.
Lean simply means using less to do
more.
Lean Management
Embraces 5 principles
■
■
■
■
■
Value-What is the customer willing to pay
for?
Value Stream-Steps to deliver the value
Flow-Organizing the Value Stream to be
continuous
Pull-Responding to customer demand
Perfection-Relentless, continuous
improvement(Kaizen)
Value Added vs. Non Value Added
■
Value Added Activity
– Any activity that impacts output or
outcome for the customer
■
Non Value Added Activity
– Any activity that DOES NOT impact output
or outcome for the customer
Toyota Production System (TPS)
Historical Perspective
■
Between 1948 and 1975, Taiichi Ohno
Shigeo Shingo and Eiji Toyoda, develop what
is now referred to as the Toyota Production
System (TPS).
■ It combines attitudes, themes and specific
problem solving techniques into an integrated
socio-technical system for manufacturing.
■ More recently, healthcare organizations have
adopted and adapted the TPS to help
negotiate the ever changing healthcare
environment.
Toyota’s 14 Principles
1.
2.
3.
Management decisions should be
made with long-term vision, in lieu of
short term financial goals
Create continuous process flow to
help bring problems to the surface.
Use Pull systems to avoid
overproduction.
Toyota’s 14 Principles
4. Level out the workload
5.
6.
7.
8.
Build a culture to stop and fix
problems to get it right the first time
Standardize processes and tasks
Use visual control
Use reliable technology
Toyota’s 14 Principles
9.
10.
11.
Grow leaders to help perpetuate the
culture and teach it to others
Develop exceptional people
Extend your network of partners
challenging them to improve
Toyota’s 14 Principles
12.
13.
14.
Go see for yourself to help thoroughly
understand the situation
Make decisions slowly by consensus,
considering all options, implement
decisions rapidly
Become a learning organization
through reflection and continuous
improvement
Toyota Principle # 10
Go to the Gemba
■
Gemba - Japanese for the actual place. In
management terms this can mean going to
where value is created. Going to see the
actual place: the source of the problem. The
goal is to gain understanding by observing
the actual circumstances in which a
product/service is used/provided then
determine where and when improvements
and innovation are possible. This is the
cornerstone of the A3 Process.
Facts from paper are not the same as
facts from people. The reliability of the
people giving you the facts is as
important as the facts themselves.
~Harold S. Geneen
TPS and the A3
■
■
A3 thinking is a problem solving tool
that was developed and used
extensively at Toyota which utilizes
Deming's PDCA (Plan-Do-Check-Act)
improvement cycle.
The following slides will further explain
the process
The Power of the A3
■
■
■
■
■
■
■
■
The A3 offers a simple and consistent way to achieve and
document root cause analysis
Accountability occurs naturally
Testing establishes a safe, experimental attitude and
environment
Management and staff learn to see problems the same way
A3 problem solving occurs as part of everyday work
The A3 process documents costs and benefits
The A3 template helps us solve problems and document new
processes
The A3 process is satisfying to everyone, particularly frontline
workers
A deep understanding of the current conditions is essential to
avoid ‘jumping to conclusions.
Cindy Jimmerson, Lean Healthcare West in Missoula, Montana
Erroneous assumptions can be disastrous.
~Peter Drucker
Good management is the art of making
problems so interesting and their
solutions so constructive that everyone
wants to get to work and deal with them.
~Paul Hawken, Natural Capitalism
Plan-Do-Check-Act
■
■
The PDCA cycle is the basis for A3
thinking.
The importance of planning is stressed.
Toyota’s Principle 12—clearly
encourages careful planning,
consensus building and rapid
implementation.
Plan-Do-Check-Act
■
Plan: Define the system, assess the current
situation, analyze causes and develop
experiments/improvement theories.
■ Do: Run the experiments/improvement
theories.
■ Check/Study: Evaluate the results to
determine if the experiment worked.
■ Act: Standardize you new process or begin
the cycle again depending on the results.
The A3
■
■
■
■
■
The next slide is an example of an outline that would
be utilized to develop an A3.
As the form would indicate, the majority of the time is
spent in the planning phases which include:
Background, Current conditions, Goals/Targets, and
Analysis.
The Do phase is represented by the Proposed
Countermeasures.
The Check phase is incorporated into the
Plan/Results.
The Act phase occurs during follow up.
TITLE:
ANALYSIS:
BACKGROUND
Answers the question, “Why are you talking about it?”
CURRENT CONDITIONS
Choose the simplest problem-analysis tool that
clearly shows the cause-and-effect relationship: 5 whys,
fishbone, charts, continuous improvement tools, visual
aids.
Answers the question: “What is the root cause(s) of the
problem?”
What’s the pain/symptom? Just the facts.
Summary, visual, map, pareto diagram, tally sheet, histogram,
scatter diagram, control chart, graph
Answers the questions, “Where do things stand today?”
Countermeasures, Options and Evaluation
Answers the questions: “What is your proposal to reach
the future state, the target condition? How will your
recommended counter-measures affect the root cause(s)
to achieve the target?
Plan:
GOALS/TARGETS: specific,
measurable, brief, one or two bullets
Answers the question: “What specific outcomes are required”
Answers the question: “What activities will be required for
implementation and who will be responsible for what and
when? What are the indicators/measures of performance
or progress?”
Just One Technique
The 5 Whys
■
■
A problem solving technique that looks
at the end result of a process to reflect
on what caused it.
By asking the question "Why" the
symptoms can be separated from the
causes of a problem. This is important
because symptoms may often mask the
root causes of problems
A relentless barrage of "why’s" is the best
way to prepare your mind to pierce the
clouded veil of thinking caused by the
status quo. Use it often.
~Shigeo Shingo
Advantages of the 5 Whys
■
■
■
■
■
■
Simplicity
Effectiveness
Comprehensiveness
Flexibility
Engaging
Inexpensive
The 5 Why Process
1. Write down the specific problem. Writing the issue
helps you formalize the problem and describe it
completely. It also helps a team focus on the same
problem.
2. Ask Why the problem happens and write the
answer down below the problem.
3. If the answer you just provided doesn't identify the
root cause of the problem that you wrote down in
step 1, ask Why again and write that answer down.
4. Loop back to step 3 until the team is in agreement
that the problem's root cause is identified. Again, this
may take fewer or more times than five Whys.
5 Why Worksheet
www.qualitytrainingportal.com/.../5whys.gif
www.qualitytrainingportal.com/.../5whys.gif
If you don't ask the right questions, you
don't get the right answers. A question
asked in the right way often points to its
own answer. Asking questions is the
ABC of diagnosis. Only the inquiring
mind solves problems.
~Edward Hodnett
TPS Principle # 6
Standard Work
■
■
■
■
■
Documentation of the least wasteful way of
completing an activity/function.
Best Practices are incorporated into standard
work.
Standard work is the basis for all continuous
improvement activities.
Eliminate Work-arounds
One way to help organize work and work
areas is time utilize the 6s process.
Engagement Study
Muhlenberg Behavioral Health
■
Background
– July 2008 thru October 2008
• Poor compliance with initial appointments
• 228 scheduled initial appointments
• Show rate 79%--48 unused appointments
• Yearly projection of unused appointments=144
• Patient complaints regarding lack of access
Current Conditions
■
■
No engagement of client with outpatient
program
Patients’ expectations and perceptions
unclear
Goals/Targets
■
Increase show rate by 5-10%
Analysis
■
Root cause-poor connection with OP
provider-lack of engagement
Countermeasures/Plan
■
■
Contact patient 2-3 days prior to appointment
Utilize script to engage patient in the
treatment process
■ Explain nature of the visit and expectations
■ Answer any questions
OUTCOMES
No Contact (n = 12)
Left a Voicemail (n = 234)
No-show
18%
No-show
50%
Kept
50%
Cancelled
6%
Kept
76%
Cancelled
0%
Left Message w/ Other (n = 77)
Spoke w/ Patient
No-show
4%
No-show
6%
Cancelled
2%
Cancelled
6%
Kept
88%
Kept
94%
(n = 219)
OUTCOMES
First Appts: Nov 08–Aug 09
(n = 542)
Overall Compliance improves from 79% to 85%
No-show
11%
Cancelled
4%
Kept
85%
Future Plans
(initially developed after analysis of the data)
■
■
■
■
■
Develop complementary “script” for referring
providers
Get “best” contact # from patient – ask the patient,
esp if cell phone desired
Develop enhanced program brochure for hand-out
at D/C, with name & # to call at any time before first
appt
Roll out to other outpatient programs
Implement post discharge calls 2-3 post discharge
to “check in”.
What steps did we take?
■
■
■
■
■
■
Got “best” contact # from patient – ask the patient,
especially if cell phone desired
Developed enhanced program brochure for hand-out
at D/C, with name & # to call at any time before first
appt
Rolled out to other outpatient programs
Encouraged internal providers (higher levels of care,
e.g. partial and inpatient). Call for outpatient
appointment at admission.
Called patient post discharge from higher levels of
care.
Screened internal referrals more effectively.
Follow up data
■
The following charts represent the
finding of a study at Muhlenberg
Behavioral Health
– Conducted FY 10—July 1, 2009 thru June
30, 2010.
NO CONTACT (n=28)
LEFT VOICEMAIL (n=350)
No-show, 4,
14.29%
No-show,
43, 12.29%
Cancelled,
14, 4.00%
Cancelled,
1, 3.57%
Kept, 23,
82.14%
Kept, 293,
83.71%
Kept
Cancelled
No-show
MESSAGE WITH OTHER
(n=84)
No-show, 3,
Cancelled,
3.57%
7, 8.33%
Kept, 74,
88.10%
SPOKE WITH PATIENT (318)
No-show, 8,
Cancelled,
2.52%
10, 3.15%
Kept, 299,
94.32%
All Referrals
FY 10
Cancelled,
38, 4.83%
No-show,
60, 7.62%
Kept
Cancelled
No-show
Kept, 689,
87.55%
What next?
■
Out of our initial study, it was
determined that we needed to focus on
our internal referrals since the noshow/cancellation rate for those
individuals was higher than the general
population.
Background
Poor compliance with initial appointments.
Lowest compliance was actually
discharges from higher levels of care.
Compliance is key to:
Reducing readmissions
Improving quality of care
Ensuring patient safety
Current Conditions
Poor compliance and extended wait times
create the following issues:
■
■
■
■
■
Delivery: wait times 2-3x acceptable standard
Delivery: 25-50% no-show rate for initial
appointments
Quality: Impedes continuity of care and patient
safety
Cost: Impacts revenue & growth
Quantity: Creates rework-Scheduling & rescheduling,
etc.
Goals/Targets
■
■
■
■
■
Improve waiting time to 7-14 days post
discharge
Improve initial appointment compliance
to at least 85%
Improve patient satisfaction
Improve referral source satisfaction
Reduce readmissions
Analysis
■
■
■
■
■
Patient safety and continuity of care
negatively impacted by long wait time
Waiting time for appointments exceeds
acceptable standards by 2-3 times
25-50% no-show rate for initial appointments
ER visits prompted by long waiting period
Difficulty connecting with OP programs
Proposed Countermeasures
■
■
■
■
■
■
■
Engagement Process
Clarify inclusion-exclusion criteria
Standardize referral process
Develop insurance matrix for Higher Levels of
Care (HLC)
HLC connect with OP provider at admission
Obtain best contact number for patient
Post discharge calls
Proposed Countermeasures Chart
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W W M S S W W W W S W
M S W W M S M S S W M
S
S
Improve member satisfaction**
W M W M S M S M M M S
Improve patient satisfaction*
M
20 days <14 days
S M W M M S M
S
S
S
S
<15%
28%
Performance Outcomes
Reduce the number of no-shows from LVHN
higher levels of care
Reduce waiting time for initial appointments
to acceptable industry standards
In Development
S= Strong Relationship
Completed and implemented
M= Moderate Relationship
Being explored
W= Weak Relationship
Plan
■
Meet with inpatient and partial social
workers regarding the following:
– Begin discharge process on day of
admission-allowing lead time for the
outpatient programs.
– Review inclusion-exclusion criteria
– Assess their concerns regarding the
referral process
Plan continued
■
■
■
■
■
■
Implement post discharge calls
Dedicated line for internal referrals
Standardize referral process
Distribute flyers to programs to give to
the patients upon discharge
Reminder calls
Monitor wait time via intake database
Wait time FY10
% Internal Intakes Meeting Criteria <15 days Post Discharge from a Higher Level of Care
150.00%
100.00%
100.00%
93.75%
86.36%
83.33%
72.22% 80.00% 66.67% 73.85%
75.00%
70.59%
66.67%
55.56% 52.63%
50.00%
0.00%
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Month
% Meeting Criteria < 15 days Goal
Apr
May
Jun
YTD
% of Kept Appointments
120.00%
94.12%
100.00%
80.00% 70.00%
77.78%
57.89% 56.25%
60.00%
68.18%
90.00%
87.50%
83.33%
77.78%
100.00%
72.54%
48.15%
40.00%
20.00%
0.00%
Jul
Aug
Sep
Oct
Nov
Dec
% Kept Appts (discharges from higher levels of care)
Jan
Feb
Mar
Apr
May
Jun
% Kept Appts (discharges from higher levels of care) Goal
YTD
RESULTS
■
■
■
Decreased average wait time from 25
days to 11.
Increase show rate from 62% (112
referrals, 69 kept appts.) to 88% (82
referrals, 72 kept appts.)
Increase % of patients scheduled within
15 days of discharge form 71% to 82%.
Evaluation
■
■
■
■
Discontinue post discharge calls, unable
to reach patients, not net effect.
Continue engagement calls.
Enforce inclusion-exclusion criteria.
Monitor wait time and intervene as
necessary.
Another Case for A3 thinking
■
Background
– Increase in accounts receivables and
increased referrals to collection.
One Definition
■
Buffing the Chart
– Verifying benefits
– Checking authorizations
– Checking visit limits
– Checking for claims issues
– If issues were encountered, the
situation would be dealt with at that
time.
Current Conditions
■
■
■
■
■
Total time spent in the process of preparing
charts to posting charges was consuming on
average 6-7 hours/day of staff time.
Continued errors and an excessive amount of
rework. Mistakes along the process were
increasing the amount of follow up required
by the Billing Coordinator.
Patient’s being sent to collections.
Increase in A/R.
Increased billing errors.
Goals and Targets
■
■
■
■
■
Decrease the amount of time spent
preparing charts.
Decrease A/R.
Decrease accounts in collection.
Decrease write offs and lost revenue
amounts.
Decrease posting time.
Analysis
What is the root cause?
1.
2.
3.
4.
5.
Utilized the 5 Whys
Why is it taking more time to complete the
posting cycle?
Why is the work not evenly distributed?
Why are staff not performing the tasks at
the time events are occurring?
Why are staff not entrusted to perform the
tasks?
Why are staff not cross-trained to perform
multiple tasks?
Countermeasures and Options
■
■
■
Cross train staff to perform all aspects
of the posting cycle.
Standardize the benefit verification form
and process by utilizing the technology
available in our billing system.
Establish a workflow process that
distributed the workload and minimized
rework and errors.
Plan
■
Standardize a template for benefit
verification. The template would be used for
all accounts and would be stored
electronically.
■ Staff would be trained in posting charges at
the time they are received.
■ Establish a step by step process that utilizes
staff potential and decreases opportunities for
mistakes.
Outcomes
■
Standardized template for benefit verification
information created and implemented.
■ Reduced A/R.
■ Reduced amount of time for posting process
for Billing Coordinator from 3-4 hours to 1 ½
hours with no increase in time spent by other
support staff.
■ Reduced time to post charges.
One last follow-up
■
■
Due to the reduction in posting time, our
billing coordinator was able to devote
more time to past balances.
Over the first five months of the project
we have collected over $16K in past
balances.
We should work on the process,
not the outcome of the
processes.
~Edwards Deming
Questions???
References
Berczuk, C. (2008). The Lean Hospitial. The Hospitalist, 29-31.
Kotter, J. (2001). What Leaders Really Do. Harvard Business Review, 79 (11), 85-96. Retrieved
from the Health Business Fulltext Elite Database.
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