Business Process Reengineering in Health Care IT Types of BPR Project Management Implications Examples from the Field 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

Group 4: Project Agenda Overview of Business Process Redesign models used in healthcare. Applicability of principles of Business Process redesign related to overall Project Management methodologies. Effectiveness of such models as part of a Healthcare IT initiative. Examples where organizations have used such a model as part of a Healthcare IT initiative. Class exercise and questions.

Health Care Challenges that encourage BPR Medical errors and high costs of healthcare Underinsured or uninsured population Increasing number of heterogeneous and older population, Globalization/ medical outsourcing, Maintaining quality for given cost and cost minimization for given quality Shortage of clinical and nursing staff

Expectations from BPR models Increase in efficiency Reduce medical and medication errors Health care cost reduction Better access and quality in healthcare Procedure optimization Time effectiveness Customer and health care provider satisfaction

Highlighted solutions Automating and monitoring processes in healthcare Redesigning or improving clinical processes where necessary and possible Identifying patient expectations and improving patient care processes for better customer services. BPR models: The business process redesign (BPR) models are the processes that target improvisation and optimization of process outputs while maintaining quality.

Six Sigma (Six sigma was invented by Motorola in the 1980s) Analytical approach to indentify the inefficiencies and inadequacies in the process and provide a step by step solution based on analysis of real time data. Process must have < 3.4 defects per million occurrences (Carrigan, 2006) Statistical calculation that suggests customer needs /satisfaction to meet 99.99997% or 6-Sigma level. (Caldwell 2006) Focuses on customer satisfaction, process improvement and cost reduction. (Breyfogle, 2003) Uses structured methodology and powerful statistical tools that provide a scientific approach to process improvement and patient safety. (http://www.medscape.com) Six sigma was invented by Motorola in the 1980s. Although Lean and Six Sigma are originally business management models, in recent years the potential of these techniques in health care and in software development is been recognized. (Schweikhart et al 2009)

Six Sigma Sub methodologies DMAIC: Define, Measure, Analyze, Improve, and Control; (improve existing processes ) DMADV: Define, Measure, Analyze, Design, Verify; (develop new processes or products at Six Sigma quality levels) (http://www.isixsigma.com/sixsigma/six_sigma.asp) Implementing 6sigma: “Black Belt” = organize of Six Sigma project “Green belt” = implement and monitor the project. Define and describe the potential critical processes. Determine measures such as accuracy standards, reproducibility of each process, idendify and verify cause effect relationship between variables, implement the improvement design and establish control over new system via policies/ regulations and document to prevent recurring issues. DMADV has last 2 steps different: Design new process and verfy that the solution fits the problem. People in an organization are certified to implement Six Sigma by allotting them “Black Belt” or “Green belt” status. Black belts organize the Six Sigma project and green belts implement and monitor the project. Sigma is a statistical calculation that suggests customer needs /satisfaction to meet 99.99997% or 6-Sigma. Majority of the times healthcare processes rarely go beyond 93% or 3 sigma.

Applications of BPR models: Scheduling appointments Emergency room allotment Diagnostic imaging Patient follow up appointments Cancer screenings Bed allotment systems Minimizing duplication of records, bills, scheduling of follow ups and refills Reduce “off time” of the systems to improve accessibility and promptness Reducing wait times at Dr.’s office and many more.

BPR Obstacles Internal and external challenges such as resistance to change, financial challenges, hierarchical tensions, changing workforce, lack of commitment, lack of implementation Six Sigma requires a clear goal setting, ample training of employees and commitment to implement the projects thoroughly. success is not guaranteed (Corn 2009)

Business Process Reengineering and Health Care IT IT often plays a support role in BPE in health care “What has to happen when you design the new process, you find how information technology is going to be used to support that new process, and if you don’t have that technological capability, you’re going to have to go and get it.” (George W. Whetsell) CIO has to understand BPR as it applies to his or her specific organization and be innovative in applying that understanding to the IT function within the organization. 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow Denver Health (Lean) Pure IT project: patient scheduling application development Project timeline reduced 50%, outside consulting cost reduced 36%. IS had previously sat “on the sidelines” in lean initiatives, but sought to use lean to make the department more efficient Challenge was to fit lean concepts to a longer term IT project. 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow Denver Health (Lean) Rapid Improvement Event (RIE) model was tweaked to fit this specific project Embedded into project cycle, redefining how project was managed Custom templates created Special attention given to lean tools, activity flow, and frequency of RIE events Involvement of end users “Red phone” mentality Used MS Sharepoint to bring stakeholders up to speed with 15 mins of relevant information Delta team of 3 individuals replaced project governance and took day-to-day responsibility for decision making 25% reduction in internal resource time spent on the project Training time reduced because trainers were involved from the beginning and became application experts. Training materials were available before launch, and 80-90% of users were trained ahead of time. 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

VA’s VistA QUERI system (TQM) Quality Improvement initiative within the VA, where data from the organization’s nationwide interoperable VistA EMR system is integral to the total process of improving patient outcomes. 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow the structure of the VA and the access to data provided by VistA make it a natural fit for research activities seeking to improve quality, clinical outcomes, and patient satisfaction. As Kizer et al state, “The VHA’s unique portfolio of providing patient care, teaching, conducting research, and continuously measuring outcomes, combined with its large size and national presence, provide for a broad and stable patient base for taking research discoveries and quickly putting them to work, either to improve patient care or to enhance system efficiency. QUERI attempts to purposely link research activities (which generate scientific evidence) to clinical care in as close to real time as possible, thereby leading to rapid adoption of best clinical practices and improvement in patient outcomes.” (Kizer, Demakis, & Feussner, 2000). Hynes, D. M., Perrin, R. A., Rappaport, S., Stevens, J. M., & Demakis, J. G. Informatics Resources to Support Health Care: Quality Improvement in the Veterans Health Administration. Journal of the American Medical Informatics Association. 2(5), 344-350. 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow Virginia Mason (Lean) IT served as a support role to improve areas identified as cost-centers Implementation of CPOE to reduce unnecessary prescriptions and reduce ER visits due to low refill allowances Implementation of decision support to alert clinicians when tests fall into the “not useful” category The problem: high cost for treating migraines and GERD, initially attributed to specialists, but through process scrutiny, late attributed to primary care docs and ED docs. 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

Bibliography Corn, J.B., Six Sigma in Health Care, Radiologic Technology. September/October 2009; 81(1): 92-95 Bergman, R. (1994). Reengineering Healthcare. Hospitals & Health Networks. 5 February, 1994, 28-36. Breyfogle, F.W., Implementing Six Sigma: Smarter Solutions Using Statistical Methods, 2nd ed. 2003, Wiley, New York, NY. http://www.isixsigma.com/sixsigma/six_sigma.asp) http://www.medscape.com/viewarticle/449692_6) Carrigan MD, Kujawa D. Six Sigma in health care management and strategy. Health Care Management. 2006;25(2):133-141 Caldwell, C., Lean-Six Sigma tools for rapid cycle cost reduction, Healthcare Financial Management. Oct 2006, 60 (10) McQueen, H. E. (1993). The healthcare CIO’s role in business process redesign. Computers in Healthcare. February, 1993, 24-28. Schweikhart SA, Dembe AE. J Investig Med. 2009 Sep 2 Shaffer, Vi. (2008). Case Study: Denver Health Leverages ‘Lean’ for a Breakthrough in Enterprise Patient Scheduling Implementation. Gartner Industry Research. 17 December, 2008. http://www.pqa.net/ProdServices/sixsigma/sixsigma.html