Lean Process Engineering in Small Practices

1. Lean Process Engineering in Small Practices Masspro Joseph Holtschlag, Manager, DOQ-IT Harvard Quality Colloquium Aug 20, 2007

2. Session Overview • Small practices don’t 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

3. 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

4. What is a Small Practice? Iterative Independent Uncertain Reactive • 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

5. 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

6. Current State of Small Practices Iterative Independent Uncertain Reactive Care that is: Efficient Effective Patient-centered

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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 • “Can’t manage what you can’t measure” • Matching improvement efforts to objective information • Quality • Operational • Financial • Patient satisfaction • Final step in improving practice communications

13. Results • Waste becomes everyone’s 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

14. 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

15. Joseph Holtschlag Manager, DOQ-IT Jholtschlag@maqio.sdps.org (781) 419-2747 Questions?