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

 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 Session Overview

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

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 Iterative Independent Uncertain Reactive

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

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

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

How to Change Catapult of EHRProject Leadership Teams Measurement Combine to achieve Lean goals:  eliminate waste  utilize staff more effectively  reduce over-processing  decrease waiting and interruptions

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

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

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

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

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

 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 Session Conclusions

Questions? Joseph Holtschlag Manager, DOQ-IT (781)