Leveraging Lean to

Transform Care

Christopher Bowers, MHA, Director, Primary Care

Inez Jordan, LSS-MBB, Director, Process Improvement

Inez Jordan is an Executive Consultant with Integrationz

Inc. which provides Process Improvement, Lean Six

Sigma and Industrial Engineering support to a variety of

markets, including Healthcare.

Disclosure

Quick Stats

• 13 Hospitals (Owned & Managed)

• 60 Health Centers

• 1,200 affiliated physicians, including 1,040

employed, in over 90 specialties & subspecialties

• 550 Clinical Trials, 4,900 Patients

• 375 Residents and 417 Medical Students

• Largest Private Employer in Louisiana

2015 Patient Activity • 411,988 Unique Patients

• From 90 Countries

• 1.6M Clinic Visits

• More than 8,800 Regional Referrals

• More than 16,000 Telemed Consults

Who is Ochsner? Community-Based Multi-Specialty Group Practice

in the Greater New Orleans Area and

Southeastern Louisiana

Quick Stats

• 38 Locations Across Southeastern Louisiana

• 169 Physicians (IM , FM and Med PEDS)

• 63 Advanced Practice Providers (NP and PA)

• 417 Medical Students – Ochsner Clinical School,

University of Queensland

• 75 Internal Medicine Residents (ACGME)

2015 Patient Activity

• 258,859 Unique Patients

• 542,191 Clinic Visits

What About Ochsner Primary Care?

Design Issues

• Siloed Care

• Lack of Standardization

• “Loose Federation”

• Practice Variation

Key Indicators

• Unique Patients: Flat

• Visits: (4,303) y.o.y.

• RVU: (2,187) y.o.y.

• Employee Engagement:

19% Actively Engaged (29.8% HC Norm.)

Where was Ochsner Primary Care in 2012?

Lean Comes to the Rescue!

Metric Percentage

Improvement Time Period

Unique Patients 11.12% 7/13 – 8/14

Visits 8.86% 7/13 – 8/14

RVUs 10.74% 7/13 – 8/14

Employee

Engagement (Actively Engaged)

19% to 50%

(2012) (2014) 2012 - 2014

Note: Unique patients, visits, and RVUs are prior to the addition of any

new Providers.

Elements Contributing to Our Success

• Commitment to Team-Based Care Model

• Aligned Professionals operating at the “top of their licenses”

• Openness and Willingness to Optimize the Model

• Led by effective Physician-Administrator Dyads

• Provide a base of patients to support the entire health system

as a Primary Source of Referrals

Our Lean Journey – The Beginning

…6 months out from relocating a

35-Physician practice

Design Goals:

• Unique Patient Experience

• Co-Location

• Transform Care Model

• On-stage vs. Off-stage

• Visit Progression

• Standardization

Evolution of Team-Based Care

Operational Considerations

Original Condition

One Large Clinic

60 Exam Rooms With Varied Set-up

“Siloed” Practice Style

Intake and Check Out Varies by Practice

1 Central Supply Room

Future State

3 Smaller Clinics Under One Roof

96 Standardized Exam Rooms

Co-Located Team-Based Care Model

Standard Intake and Check Out Processes

1 Supply Room Per Clinic

And Move On

Our Classic Methodology

• Top-down method

• Several meetings

• Threat of scope creep

• Unclear duties and

accountability

• Beloved Check List or Form

• Plan – Do – And Move On

Take a Familiar Road?

We Discovered a Better Way…

LEAN Methodology

• Charter & Scope

• Learn to See

• Involve Frontline Staff

• Timelines and Accountability

• Improvement Science

• Sustain the Gain

Flow

Movement of products, services

and information down the

value stream

EVERYTHING YOU DO IS A PROCESS

LEAN – The Basics

The Underlying Principles Article: Prescription for engaging physicians

“Standard work should be viewed

as how we’ve designed our work to

consistently deliver safe, effective

care.”

“Without standard work, how would

anyone know if a change is

actually an improvement?”

“…Many of us have had to become "workaround artists" to get

through our day. “

Improve to Perfection

Reducing waste brings us closer to perfection Continuous improvement is the road to perfection

Define Measure Analyze Improve Control

Who are the

stakeholders and

what are their

priorities?

How is the process

performing and how is

it measured?

What are the most

important causes of

the process issues?

How do we remove the

causes of the issues and

improve the process?

How can we control

the process moving

forward?

Plan Do Study Act

DMAIC

LEAN: Minimum Resources Maximum Value

Four Basic Steps to Start LEAN

You Need an Expert Internal or External

Process Engineering

Begin with the End in Mind Focus

Early Win

Build Your Team Cascade Sponsorship

Key Stakeholders

Manage the Change Maintain Momentum

Model, Express, Reinforce

1 2

3 4

Step 1: You Need an Expert

Technical Expertise

Internal • Industrial Eng

• Process Eng

• Lean Six Sigma

Consultants • Technical Expertise

• Diverse Portfolio

• Trainer

Share Knowledge

Train Green Belts • Select Group

• Formal Training

• Lead Project Team

As You Go • Pick Project Team

• Just in Time Training

Execute

Green Belt Lead • Expert Coach

• Practical Application

• Driver Seat

Expert Lead • Main Facilitator

• Team Support

1

Step 2: Begin with the End in Mind

2 Focus ● Early Win

ACTIVTY

10 Min

Need some where to Start

Ask yourself some Questions

1. What Waste are in my Process ?

2. Talk to your staff – are they Frustrated?

3. What are Patients Complaining About?

Get Back to Basics

Look at your team

1. What are they doing vs. What should they be doing

2. Are we taking shortcuts?

Putting first things first…

• What has to be in place for day

one?

– Check In and Intake Process

– Check Out

• How do we keep supplies from

tripling?

– 5S and Kanban System

Step 3: Build Your Team

3

C Champions: Believe in and want the change . May lack sponsorship to drive

A Agents have implementation responsibility through planning and execution

S Sponsors authorize, legitimize and demonstrate ownership for change

T Targets change behavior, emotions, knowledge, perceptions etc.

“If the marksman, or archer, misses the target, it is not the target’s fault”

Cast of Characters

1. In major change there will

always be overlap in the

roles.

2. When roles overlap, Treat

the individual as a Target

first.

3. If you don’t treat them as

Targets first, they may

remain Targets forever

Implementation Management Associates, Inc.

Step 3: Build Your Team

ACTIVTY

7 Min

3 Cascade Sponsorship ● Key Stakeholders

Quick Tips

1. Team Leaders : 3 Green Belts

2. Leaders do not have to be from the Area

3. At least one Leader Non–Clinical

• Revenue Cycle

• Finance / Analytics

• IS or EMR

• Fellows

4. Targets should be Team Members

5. Anticipate Resistance

• Look for Influencers

Step 4: Manage the Change

Steering

Committee

4

Prioritize Monitor

New Internal Medicine Clinic

required standardized Intake

process for optimized

patient throughput.

• Lack of SOP

• Rooming time took an

average of 8 minutes

• Blood Pressure measured

at beginning of the process

causing misleading blood

pressure readings

• New layout of Clinic and

Intake Rooms created an

inefficient process (lack of

privacy causing Intake to be

completed in exam room)

• Non-value added time

(19%)

• Created SOP for Intake

process (including Med

reconciliation)

• Moved Blood Pressure

down in Epic Navigator

(Measure Up, Pressure

Down)

• Decreased total rooming

time from 8.03 minutes to

6.15 minutes

• Non-Value Added time

converted to Value-Added

time by engaging Patient

during transport to exam

room (Psychosocial Analysis)

• Additional 23 minutes of

exam room capacity created

(not continuous)

Primary Care Rooming Standard Workflow

What was the PROBLEM?

What was the CAUSE?

What did we TRY?

Did it WORK?

1 2 3 4

Executive Sponsors: Dr. Nona Epstein, Chris Bowers

Process Owner: Valerie Jackson, RN

Project Team: Dore’ion Stewart (MA), Katie Kirby (LPN), John Budde (Patient

Volunteer)

Lean Green Belts: James Person, Allison Maestri

Lean Coach: Inez Jordan, Lacey Momic

Enter Picture Here

Rooming Standard: Continuous Improvement

•Choose the most appropriate complaint or reason for visit

•Avoid “6 mo f/u”

Chief Complaint

•BP + Pulse + Temp

•Weight + Height + Smoking Status

•Pain Scale

Vital signs

•Review allergies with patient

•Update as needed

Allergies

•Review each med individually

•Update with “taking” or “not taking”

Medications

•Enter correct Pharmacy

Pharmacy

•Launch or decline

My Chart signup

•Notes on Rooming Sheet

Handoff

Pat

ient

Roo

min

g S

tand

ard

•Choose the most appropriate complaint or reason for visit

•Avoid “6 mo f/u”

Chief Complaint

•Temp

•Weight + Height + Smoking Status

•Pain Scale + Risk Assessments (per policy)

Vital Signs

•Review allergies with patient

•Update as needed

Allergies

•Review each med individually

•Update with “taking” or “not taking”

Medications

•BP and Pulse

Vital Signs

•Enter correct Pharmacy

Pharmacy

•Launch or decline

My Chart signup

•Notes on Rooming Sheet

Handoff

Pat

ient

Roo

min

g S

tand

ard

Primary Care Timeline: Lean Evolution

Site specific improvement opportunities for workflows around the Provider

(Registration, Checkout, 5S)

Site level and System level projects involving Provider workflows (Resident Clinic, Depression and Fall Risk Screening)

System level scaling of improvement opportunities

2014 2015 2016

Power of Improvement Your LEAN Journey

• Many of our best ideas

come from front-line staff

• Lean cultivates alignment,

engagement, and a culture

of improvement

• Seeing is believing

Sponsorship

Technical Execution

Celebrate

Re-Invest

Thank You: Q & A

APPENDIX

Primary Care Lean: How did we get there?

RESULTS:

July 2013 – July 2014

• Unique patients increased by 11.12% (3,459 unique patients)

•Visits increased by 8.86% (3,443 visits)

•RVUs increased by 10.74% (6,198 RVUs)

•Employee Engagement Scores improved from 19% (2012) to 50% (2014) for Actively Engaged Employees

Key Takeaway:

Success depends on a workforce that is engaged and competent in

process improvement, change management and project

management.

Engaged Sponsors:

Janie Gilberti

Dr. Pedro Cazabon

Steering Team: Chris Bowers

Dr. Steven Granier Dr. Leslie Blake

Dr. Nona Epstein Shannon Stanley Valerie Jackson Christine White

Lean Green Belts:

6 Certified Green Belts

4 Green Belt Candidates in 2016 (incl. Physicians)

16 Lean Projects completed in 2014 and

2015

Employee Engagement:

75% of Front-Line Employees

(incl. Physicians) participated in Primary

Care Lean events in 2014 and 2015

Lean education in Resident Clinic

Mobilized Around Making Ochsner a Better Place to Receive and Deliver Care

Nominations for Lean Training

• Six certified Green Belts

• Six Green Belt Candidates

• NOMC and Westbank locations

• Roles participating in GB Program: PCP, MA, RN, LPN, Leadership, Phone staff

Project Prioritization

• Structured Approach to Project Prioritization and Selection

• Evaluate/validate existing project funnel (as aligned to key strategies)

• Brainstorm additional opportunities (System view)

• Prioritization (B/E Matrix) and Resourcing (High Level Scoping: SIPOC)

Lean Project Work

• Follow DMAIC Methodology and Apply Lean tools/concepts

• Weekly Green Belt meetings (Reinforce classroom learning, coaching)

• Weekly or bi-weekly Sponsor/Key Stakeholder meetings

Updates to PC Leadership

• Bi-weekly or monthly updates to Steering Committee

• Review progress; Discuss barriers/challenges

• High Level project updates to Primary Care Council as appropriate

Primary Care: Lean Approach (Infrastructure)

Prioritization

Scale

(Working

Document)

Prioritization

Scale

populates

B/E Matrix

Primary Care: Project Prioritization Approach

Primary Care Project Prioritization

Kanban: IM Exam Rooms (2014)

Kanban: Allergy Exam Rooms (2014)

5S: Allergy Central Storage (2014)

Registration (2014)

Intake (2014)

Checkout (2014)

Depression and Fall Risk Screenings (2014)

HCC Provider Workflow (2014)

Physician Messaging: Phase 1 (2015)

Resident Clinic Workflow (2015)

Provider Cross Coverage (2015)

Forms Workflow (2015)

Specimen Collection (2015)

ED Handover (Jeff Hwy, expect to close 2015)

Colonoscopy Scheduling (Westbank, 2015)

Priority Clinic (Pilot phase, Jeff Hwy, 2015)

Vaccine/Immunization Workflow (Service Line, 2016)

Spirometry Screening Workflow (Service Line, 2016)

Bulk Ordering for Labs Workflow

DME Ordering

Nursing Home Referrals

Coordination of Studies (Inpatient to Amb)

Diabetes Pre-Visit Workflow

Elderly Bootcamp (Geriatric Team) / Priority Clinic (Amb

ICU)

Ochsner Home Health Referral (Outpatient)

Provider Schedules (Time Management)

First Call Resolution

MA and LPN Workflow

Health Coach Workflow

HIM Scanning of Non-Epic Data

Point of Care Testing or ASAP Diagnostic Studies

Pre-visit Planning for Chronic Diseases (Similar to new

focus of LPN CCC)

Project Funnel In Process

Completed

Primary Care Council

I have met with each person listed below, discussed the project and enlisted their support/approval:

Project Sponsor(s) (Leader who will champion project with approval authority for changes.)

Physician Sponsor (if applicable) (Champion project work and have approval authority for improvements.)

Process Owner(s) (Leader responsible for processes targeted for improvement.)

CEO/COO/CNO/RMD/MCA Core Team Sponsor Level Approver Name of Approver: __________________________

Project Name: Name of Person Submitting Project Request: Contact Information: ___________________________________email _______________phone

Support Validation - Type an “X” into each box that applies.

Charter Completion - Type an “X” into each box that applies.

I have completed a first draft of the project charter:

Project Charter Attached

Resource Deployment - Type an “X” into each box that applies.

I have identified Green Belts for this project

Green Belt 1 ________________ Green Belt 2 ________________ Green Belt 3 ________________

LEAN Project Intake Form

Checkpoint: Is Project Set Up for Success? Type an “X” into each box that applies.

Project Charter Summary (Must be Completed Prior to Submission for Coaching Resources)

Project:

In Scope: Out of Scope:

Green Belt(s): Coach:

Problem Statement:

Expected Benefits:

Measurable? Process has clear Start / Finish?

Stakeholder Capacity considered?

Scoped for Green Belt Completion? (3-4 mo.)

Targeted Start Date: Targeted Event Week (if applicable): Anticipated End Date:

Identified project team/area ready for change?

SPONSORS (Enter Names)

Name 1

Name 2

Name 3

Process Owners (Enter Names)

Name 1 Name 4

Name 2 Name 5

Name 3 Name 6

Project Team Members (Enter Names : Not Including Process Owners)

Name 1 Name 4

Name 2 Name 5

Name 3 Name 6

Select Project Stakeholders

Primary Care does not

consistently document or report

screenings for Depression or Fall

Risk in the Outpatient setting, and

was receiving a score of ZERO in

HEDIS measures

Although Fall Risk was being

assessed for every patient in

every visit, a workflow did not

exist to screen for Depression or

Fall Risk. Further, an Epic tool did

not exist to capture screening

results or track a care plan.

The Project Team collaborated to

create a workflow in Epic as well

as a Standard Operating

Procedure for all clinical staff.

The new workflow was

incorporated into the Intake

process and piloted for two weeks

in one location, allowing for any

feedback and changes.

Training and education were

completed with all Clinic Leads

(Train the Trainer) following the

pilot, and the workflow was

implemented system-wide.

Physicians reported that the

workflow was efficient and did not

adversely affect the patient visit

nor did it lengthen the visit time.

Primary Care Depression and Fall Risk Screenings Workflow

Executive Sponsor/Physician Champion: Janie Gilberti, Dr. Pedro Cazabon

Key Stakeholders: Dr. Phil Oravetz (ACO), Janet Niles (ACO), Susan Montz (ACO), Dr. Dean Hickman

(Behavioral Health), Kevan Simms (Epic)

Process Owner: Shannon Stanley, MA

Project Team: Primary Care Leadership, Primary Care MD/RN/LPN/MA, Behavioral Health, Social Work, ACO,

ACO Analytics, Epic

Lean Green Belts: Ashley Weber, Laura Carleton, Mary Lunsford

Process Improvement Manager: Lacey Momic

What was the PROBLEM?

What was the CAUSE?

What did we TRY? Did it WORK? 1 2 3 4

August '14 September '14 October '14

78.5%

99.6%

90.9%

Fall Risk Screenings

HEDIS

Goal:

73.3%

We have new questions to ask you, they wont be asked every visit, just once a year. These questions help your physician plan for your needs, please answer thoughtfully.

1. Over the past two weeks how often have you had little interest or pleasure in doing things?2. Over the past two weeks how often have you felt down, depressed, or hopeless?

Calendar Calendar

Calendar

Not at all Several Days

More than half the days Every dayCalendar

Fall Screen: Current State

Depression Screen: Current StateDepression Screen:

RESULTS Actua

l:

74.4

%

Fall Screen: RESULTS

Act.:

90.9%

August '14 September '14 October '14

62.1%

77.2% 76.4%

Depression Screenings

HEDIS

Goal:

51.81%

Depression Screen:

RESULTS Act.:

74.4%

There was much variation in

the checkout process leading

to confusion of roles and

responsibilities.

Checkout staff were

underutilized and clinic staff

were not functioning at the

top of their license.

• Lack of a standard

operating procedure

• Lack of data around the

checkout process

• Created a standard

operating procedure

• Clinic staff would hand off to

the Checkout staff to now

schedule all follow up

appointments

• Clinic staff could focus more

on patient care

Shifted work content from

MAs/LPNs to Checkout staff,

allowing all roles to function

at the top of their license.

Primary Care Checkout Workflow

What was the PROBLEM?

What was the CAUSE?

What did we TRY?

Did it WORK?

1 2 3 4

Executive Sponsors: Dr. Leslie Blake, Chris Bowers

Process Owner: Shannon Stanley

Project Team: Donna Barnewold, Suzanne Brassette, Arrian Chapman, Rupinderjit

Dhillon, Linda Walton

Lean Green Belts: Nicole Whitesides, Mike Hill

Lean Coach: Inez Jordan, Lacey Momic

Enter Picture Here

Results/Current Conditions: Checkout

Work Content Shifted to Check Out

SOP Implemented

2/3/2014

72% 68% 68%

48%

36%

14% 18% 17%

37%

45%

5% 5% 4% 3%

1%

9% 8% 11% 12% 17%

0%

0%

20%

40%

60%

80%

100%

Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Lab Appts. Scheduled by IM Clinic (As of March 14, 2014)

RN

LPN

PROVIDER-MD

Checkout

MA

Primary Care moved from a

“single clinic” with 60 exam

rooms and 1 supply room to

“three clinics” under one roof –

each consisting of 32 exam

rooms and a supply room (total

of 96 exam rooms and 3

supply rooms).

Lack of Standardization

around:

1. Supply room setup

2. Par levels of supplies

3. Supply ordering

4. Exam room setup

5. Exam room par levels

6. Exam room

• Overstocking

• Understocking

•Hoarding

• Lack of a timely ordering

process

• Supplies not protected

Supply Room Before:

• Tracked Supply Levels

• Set Appropriate Par Levels

• Created a Two Bin System

• Standardized drawers in

exam rooms and implemented

a Kanban system

Created a Two Bin System

• 22% reduction in projected

total supply expense

• Created a weekly supply

ordering rhythm

Supply Room After:

• Provider and staff satisfaction

• Standardization across clinic

• No excess on hand = no

expired

Primary Care 5S: Two Bin Supply and Kanban System

What was the PROBLEM?

What was the CAUSE?

What did we TRY?

Did it WORK? 1 2 3 4

Executive Sponsors: Chris Bowers, Dr. Steven Granier

Lean Green Belts: Laura Carleton, Jessie Hrapmann

Lean Black Belt Coach: Lacey Momic

Project Team: Donna Barnewold, Linda Walton, Suzanne Brassette

Process Owners: Valerie Jackson and Shannon Stanley

BEFORE AFTER

Primary Care 5S: Two Bin Supply and Kanban System

What Was Implemented: Exam Rooms

Kanban Cards

“I love that I can walk into any room in primary care and I know

exactly what’s in the room and how to have it replenished.”

-MD

ˈkänˌbän/… A just-in-time method of

inventory control,

originally developed in

Japanese automobile

factories