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

2.  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

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?  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

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 Care that is: Efficient Effective Patient-centered Iterative Independent Uncertain Reactive

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 EHRProject 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.  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

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