Optimizing Care Mark Murray MD, MPA

Gap Between Performance and Possibility For clinical care For clinical care For efficiency in care For efficiency in care For satisfying care For satisfying care

Gap Exists Between systems and possibility Between systems and possibility Between sites Between sites Within sites, between individuals Within sites, between individuals

Narrow the Gap Identify the gap Identify the gap Measure the gap Measure the gap Identify a goal Identify a goal Clarify the customer and the value stream Clarify the customer and the value stream Develop a process for improvement Develop a process for improvement

Goal Deliver the best care, in the best way, on time, every time Deliver the best care, in the best way, on time, every time

Customers and Value The patient (or dyad) is the customer The patient (or dyad) is the customer Value: what does the customer value Value: what does the customer value How do we deliver that value How do we deliver that value

Delivery of Value At each step we match the demand of service to the supply of service At each step we match the demand of service to the supply of service The work flows The work flows The goal is achieved if the work flows smoothly, if there is perfect balance, all the time, so that the value is delivered perfectly, on time, every time The goal is achieved if the work flows smoothly, if there is perfect balance, all the time, so that the value is delivered perfectly, on time, every time

Failures In understanding this dynamic In understanding this dynamic In flow - due to imbalances either permanent or temporary In flow - due to imbalances either permanent or temporary Role of variation Role of variation

Workflow Optimization Perfect balance of demand and supply/resource all the time Perfect balance of demand and supply/resource all the time No delays between value steps No delays between value steps No delays at the steps No delays at the steps No unnecessary steps or tasks No unnecessary steps or tasks All steps and tasks are reliable All steps and tasks are reliable Reduction of delay is the critical operational and clinical component Reduction of delay is the critical operational and clinical component

Workflow Optimization Harmonic convergence of all critical supply components Harmonic convergence of all critical supply components Six dimensions Six dimensions

Balance Is Critical System level System level Site level Site level “Department” or program level “Department” or program level Individual level Individual level

Individual Level What does the customer want What does the customer want How can we best deliver value How can we best deliver value Identification of workload balance Identification of workload balance Put our clinicians in positions to be successful Put our clinicians in positions to be successful

Individual Level Demand and Supply Demand comes from the customer Demand comes from the customer Demand for a myriad of services Demand for a myriad of services Direct service and supporting services Direct service and supporting services Focus on outpatient office delivery Focus on outpatient office delivery Supply: time is a tool Supply: time is a tool Demand has to = supply Demand has to = supply

Critical Design Elements for the Perfect System No delay- all waits are bad No delay- all waits are bad Continuity (see your own) Continuity (see your own)

No Wait Culture Every system is perfectly designed to get the results that it does Every system is perfectly designed to get the results that it does Delays are a system property Delays are a system property We can eliminate the delays We can eliminate the delays It takes a process for improvement It takes a process for improvement

Continuity Identification of demand Identification of demand Identification of population that generates the demand Identification of population that generates the demand “Panel” “Panel” Formal enrollment process Formal enrollment process Continuity is the likelihood of the demand meeting the supply Continuity is the likelihood of the demand meeting the supply Value of that linkage - satisfactions, costs, revenues and clinical Value of that linkage - satisfactions, costs, revenues and clinical

Balance Demand has to equal supply Demand has to equal supply Measure supply Measure supply Measure demand Measure demand Macro demand is panel size Macro demand is panel size

Panel Size Has to be the right size Has to be the right size Does not have to be the same size Does not have to be the same size How to identify How to identify 4 cut method 4 cut method Enrollment formal or informal Enrollment formal or informal Panel limit and formula Panel limit and formula

Formula Panel times expectant patient visits per year = physician visits per day times days worked per year Panel times expectant patient visits per year = physician visits per day times days worked per year

Value in Healthcare We sell relationship We sell relationship Optimization of relationship Optimization of relationship Constraints and limits Constraints and limits Can or should physicians do all the operational work? The clinical work? Can or should physicians do all the operational work? The clinical work?

Help Teams for operational work in order to get the work to the worker just in time Teams for operational work in order to get the work to the worker just in time The role of the operational team is to put the clinician in a position to create the successful relationship The role of the operational team is to put the clinician in a position to create the successful relationship Teams for the clinical work Teams for the clinical work

Clinical Care Delivered by individuals Delivered by individuals Delivered by standardized, supported and co- coordinated teams Delivered by standardized, supported and co- coordinated teams

Optimization Linkage to identified provider of care Linkage to identified provider of care Accomplished without delay Accomplished without delay Delivered in a systematic way: standardized, co-coordinated, supported team with clear accountability and leadership Delivered in a systematic way: standardized, co-coordinated, supported team with clear accountability and leadership

Process for Improvement Team Team Aim Aim Change Change Measure Measure

Principles To reduce delays for or between services To reduce delays for or between services To reduce delays at service To reduce delays at service To improve clinical care To improve clinical care

Summary Optimization requires us to follow the customer and to understand the dynamic Optimization requires us to follow the customer and to understand the dynamic The patient is the customer and the dynamic is matching demand to supply The patient is the customer and the dynamic is matching demand to supply The most effective, efficient and satisfying systems will match the demand to the supply without delay The most effective, efficient and satisfying systems will match the demand to the supply without delay Matching requires balance Matching requires balance

Summary Continued The balance has to be achieved at all levels, down to the individual physicians level The balance has to be achieved at all levels, down to the individual physicians level Any imbalance creates expanding delay or turbulence Any imbalance creates expanding delay or turbulence Continuity is king Continuity is king Panel is measurement of demand and workload Panel is measurement of demand and workload Continuity is measure of successful action Continuity is measure of successful action

Implications IF we see this, what are the system implications IF we see this, what are the system implications

Implications: Wait Time With the right balance, we can eliminate delays With the right balance, we can eliminate delays Have to deal with variation Have to deal with variation What is the focus: waits or variation What is the focus: waits or variation

Implications: Panel Workload balance requires balance at all levels Workload balance requires balance at all levels “Panel” is the individual level “Panel” is the individual level Panel has to right size Panel has to right size Continuous measurement of panel is required Continuous measurement of panel is required Accountability is driven to the dyad level Accountability is driven to the dyad level

Implications: Satisfaction With increased continuity satisfaction will rise With increased continuity satisfaction will rise Offers opportunity for self care Offers opportunity for self care Offers opportunity for leverage both internal and external Offers opportunity for leverage both internal and external

Implications: Clinical Care With reduced waits and with increased continuity, clinical care will improve With reduced waits and with increased continuity, clinical care will improve We need to measure We need to measure We need to look for unique opportunities for leverage presented by short delays and improved continuity We need to look for unique opportunities for leverage presented by short delays and improved continuity The best clinical care is not achieved by visits alone The best clinical care is not achieved by visits alone

Implications: Cost With improved continuity and less waits there is less system cost: rework, redundancy, triage, no shows With improved continuity and less waits there is less system cost: rework, redundancy, triage, no shows Less visits per patient per year Less visits per patient per year Less workload at the continuity visit Less workload at the continuity visit Reduced visit length, more visits possible Reduced visit length, more visits possible

Implications: Visits Less visits per patient per year Less visits per patient per year Opportunity for increased replacement visits by growth Opportunity for increased replacement visits by growth External growth External growth Internal growth Internal growth

Implications: Net Revenue Gross revenue minus cost Gross revenue minus cost Cost goes down Cost goes down Visits go down but can be replaced Visits go down but can be replaced Visit length with continuity is shorter Visit length with continuity is shorter Visits or visit length with “team” is reduced or shorter Visits or visit length with “team” is reduced or shorter