(Title) Name(s) of presenter(s) Organizational Affiliation Welcome Back Fee-for-Service Kentucky January 31, 2012 Project Funded by CSAT

"Never invest in any idea you can't illustrate with a crayon." – Peter Lynch

E x e c u t i v e S p o n s o r C h a n g e L e a d e r C h a n g e T e a m People W a l k - t h r o u g h F l o w c h a r t i n g N o m i n a l G r o u p T e c h n i q u e P D S A C y c l e Tools Rules Use existing resources Measure change I m p r o v e m e n t Process M o d e l Change Project aim Sustain the gains

(Title) Name(s) of presenter(s) Organizational Affiliation Who’s Who in Process Improvement?

Executive Sponsor Authority to Allocate resources

Executive Sponsor Responsible for Communicating the Vision Martin Luther King

Executive Sponsor Sees change as a priority Barack Obama, President

Executive Sponsor Empowers the change leader

Change Leader Reggie White Someone who is comfortable providing day-to-day leadership, energy and enthusiasm Has the power and prestige to influence people at all levels of the organization

Change Leader Oprah Winfrey Michelle Obama Focuses the team on the change team objective Uses mandates

Change Leader Queen Rania of Jordan Challenges the status quo Reports directly to the Executive Sponsor Gets results mandated by data

Change Team Members Samaritan Village, Inc. Jamaica Outpatient Program Staff and supervisors in the work area where changes will be made Customers, family, caregivers People with special knowledge Others who are affected by the change

Change Team Responsibilities Identify possible changes that could meet the objective Decide how to implement the change Create and conduct rapid-cycle pilot tests until goal is achieved Collect data Study results to see if the change should be adopted, adapted or abandoned

Key Roles: Change Team Focus on AIM LOCATION POPULATION

What makes this approach to change different? Change is a big experiment No mistakes, no right or wrong Data tells you if the change was an improvement Customer guides change ideas

Too often we design processes to meet the organization’s needs and not the needs of the customer.

The Fee-for-Service project will help addiction treatment providers develop the capacity to bill third party payers Design a billing system (Level 1) Improve the billing process to increase collections (Level 2) Our Mission

Use small scale, rapid cycles (PDSA cycles) to break change into manageable pieces For example: –Create one bill –Eliminate the most common reason that claims get denied Applying the NIATx Way to Improve the Billing Process

Learn how to streamline the billing process for one third party payer. Then, do the same for another third party payer. Apply what you learn with MCO’s. Later: Focus on attracting more clients with the desired third party payer. Applying the NIATx Way to Improve the Billing Process

Model for Improvement 3. What changes can we make that will result in an improvement? 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? Reference: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide P D S A

The Ball Pass Exercise Discussion Questions: What did you learn about rapid cycle changes? How did you decide on a change? Were you able to implement one change at a time? Did you decrease the amount of time required? Why is it important to collect baseline data? What changes were most effective? Experience small scale, rapid cycles: The Ball Pass Exercise

AIM: to pass the ball from person to person as quickly as possible. RULES: –Only one person may touch the ball at a time; each person must touch the ball with both hands. –The ball must be passed to a person who is not right next to you. –The cycle begins when the Change Leader passes the ball the first time and ends when the Change Leader has the ball at the end. Prepare a Change Project Form and document information about each PDSA cycle.

The Ball Pass Exercise Select a: –Change Leader –Data Recorder Cycle #1 (baseline): –Stand in a circle. –The Change Leader passes the ball to another person in the circle. –Each person passes the ball to another person who is not right next to them; when everyone has touched the ball, pass it back to the Change Leader. –The data recorder documents the time from the beginning to the end of the cycle (baseline data)

The Ball Pass Exercise Conduct at least 3 PDSA cycles –PLAN: What can we do to reduce the time required? –DO: Implement the change and measure how long it takes. –STUDY: Did we get the results we expected? Was the change implemented as planned? –ACT: Adopt, adapt or abandon this change idea and decide what the next cycle will be. –Repeat another PDSA cycle.

The Ball Pass Exercise Tell your story: Create a graph to show the data for each PDSA cycle, noting the change that was made for each cycle.

The Ball Pass Exercise Discussion Questions: What did you learn about rapid cycle changes? How did you decide on a change? Were you able to implement one change at a time? Did you decrease the amount of time required? Why is it important to collect baseline data? What changes were most effective? Designing Change Projects

Model for Improvement 3. What changes can we make that will result in an improvement? 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? Reference: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide P D S A

Designing Change Projects Unfocused improvement efforts are a waste of time and resources

Sample Aim Statements Create a billing process to bill one new third party payer (Anthem) by June, Increase the collection rate from 60% to 70% by June, (Start with Anthem) Reduce the denial rate for invoices submitted to Anthem from 52% to 35% by June, 2012.

Designing Change Projects ON the Change Project Form

(Title) Name(s) of presenter(s) Organizational Affiliation Flowcharting

Why Flowchart? Flowcharts force an organizational focus on process.

Why Flowchart? Flowcharting is useful for: 1.Providing a starting point to understand the process as it is today. 2.Identifying key problems/bottlenecks 3.Showing where to test ideas for most impact 4.Adding interactivity & fun - gets the team together 5.Creating a simple & succinct visual process overview

Setting up a flowchart Where does the process begin? Where does the process end? START END Verifying Coverage. Document authorization limits Client makes first contact Title the process you are flowcharting.

Key Symbols for Flowcharts ? No Yes A square identifies a step in the process A diamond is a decision point in the process and asks a “yes or no” question or offers a choice of direction in the process. Action Post-It Notes are great for flowcharting.

Sample Flowchart Process name: Billing Process Ask about ins. at first contact

Before You Start 1. Identify a Change Leader to lead the flowchart discussion. 2. Choose one person’s organization and complete the flowchart exercise. Change Team Assignment

Flowchart the billing process. Remember the steps to follow: 1.Define where the process begins and ends 2.Give your flowchart a title: e.g., “First Contact to Document authorization limits” 3.Define process steps 4.Review/refine flowchart 5.Identify problems and bottlenecks Are there steps on the “Who does what chart” that no one is assigned to? 6.Customer barriers

Large Group Discussion 1. Useful? 2. How could you use your flowchart to help engage your organization in the change process?

The Ball Pass Exercise Discussion Questions: What did you learn about rapid cycle changes? How did you decide on a change? Were you able to implement one change at a time? Did you decrease the amount of time required? Why is it important to collect baseline data? What changes were most effective? How to Measure the Impact of Change

Learning Objectives The importance of data in a change project. A six-step process for the effective measurement of the impact of change.

Model for Improvement 3. What changes can we make that will result in an improvement? 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? Reference: Langley, Nolan, Nolan, Norman, & Provost. The Improvement Guide P D S A

How will you know which changes worked and which did not? How will you know which changes resulted in an improvement? Which change(s) is the most important and resulted in the most significant improvement? Data answers three common change project questions…..

Data directs the action steps toward a change project improvement goal.

Keep data collection and reporting as simple as possible, but be specific. Denial tracking for Anthem

A Step Process for Measuring the Impact of Change 6 6

6 Steps for Measuring the Impact of Change Always ask why. 1 DEFINE YOUR AIM & MEASURES 1 DEFINE YOUR AIM & MEASURES 2 COLLECT BASELINE DATA 2 COLLECT BASELINE DATA 3 ESTABLISH A CLEAR GOAL 3 ESTABLISH A CLEAR GOAL 4 CONSISTENTLY COLLECT DATA 4 CONSISTENTLY COLLECT DATA 5 CHART YOUR PROGRESS 5 CHART YOUR PROGRESS 6 ASK QUESTIONS 6 ASK QUESTIONS

1. Define your measures. This ensures that the results are interpretable and accepted within the organization. Clear definitions of your measures should: - Clarify project objectives - Be agreed upon by stakeholders

2. Collect baseline data. QUESTIONS TO ASK: A. Was the data defined to ensure that we collect exactly the information needed? B. How accurate is the data? Does accuracy matter? C. Does the process ensure that the measures will be collected consistently? D. Do trade-offs exist? Is quality more important than the time required to collect data? Never start a change project without it.

3. Establish a clear goal. This ensures that the results are interpretable and accepted within the organization. A goal should: - Be realistic yet ambitious - Be linked to project objectives - Avoid confusion

4. Consistently collect data. Regular data collection is a crucial part of the change process. As a team, decide: Who will collect the data? How will they collect it? Where will the data be stored?

5. Chart your progress. Use visual aids for sharing the data. Use visual aids for sharing the data. Share pre-change (baseline) and post-change data with: - Change Team - Executive Sponsor - Others in the organization Line graph

A simple line graph example Remember: One graph, one message. Goal

6. Ask questions. What is the information telling me about change in my organization? Why was one change successful and another unsuccessful? Always ask why.

Possible AIM Measures (from the Dashboard) Denial Rate Collection Rate Focus on one payer

Possible Cycle Measures To focus on reducing the # of denials for a specific reason –# of clients matched with a clinician with appropriate license (if bills are denied because service was provided by clinician without appropriate license) –# of days between service and sending bill (if bills are denied because they weren’t submitted in a timely manner)

Begin to fill out How to Measure the Impact of Change Worksheet

(Title) Name(s) of presenter(s) Organizational Affiliation Collaboration Why?

Capture the wisdom of the Change Team and participants in the Collaborative Be willing to share and exchange ideas Participate actively and dialogue Share and copy best practices Divide work tasks and empower others to help 5 Steps to ensure a successful Collaborative:

"If you have an apple and I have an apple and we exchange these apples then you and I will still each have one apple. But if you have an idea and I have an idea and we exchange these ideas, then each of us will have two ideas.“ George Bernard Shaw

(Title) Name(s) of presenter(s) Organizational Affiliation Review and Next Steps

Review How-to Steps for the NIATx Process Improvement Model

Review Use The NIATx Third-Party Billing Guide to identify steps in the process that need to be implemented.

Review Are you likely to reach your wildest dreams for the outcome of this collaborative?

Call to Action Monthly: Send Lynn and Elizabeth your updated Change Project Form Attend monthly NIATx webinars: Level 1 – 2 nd Tues. at 3 pm EST Level 2 – 2 nd Wed. at 3 pm EST Attend monthly KY provider calls

Contact Information Lynn Posze, Convener Elizabeth Strauss, NIATx Coach Jeanne Pulvermacher, NIATx

Thank you! Celebrate