Partnering to achieve the NEXT LEVEL of Performance

NEXT LEVEL Partners® HealthCare

For More Information, Contact:

Brian S Maready, Vice President-Lean Healthcare, www.nl-p.com

bmaready@nl-p.com, Cell: (719) 330 5604

Sampling of Client Success Stories

Revenue CycleStory

Peri OpStory

EDStory

Patient FlowStory

Revenue Cycle Case Study

•Denials have increased over 400% between 2011 – 2017

•$6.1M/month in denial charges• Unnecessary delays in receiving payment

• Excessive time spent on denial management & resolution

• Senior VP of Revenue Cycle reached out to NLP for help

2

System Wide

Situation Summary

• Reduce denial quantity and total charges by 30%

• Identify Pilot Hospital and Area of Focus

• Improve Productivity by reducing time spent working on denials

3

Client Objectives

• 6 month target timeframe

• Complexity of process requires multi-disciplinary teams

Other considerations

• Pilot hospital - 800 beds, 12,000 in-patient admissions per year

• Planned roll out to 4 additional sites4

Approach

• 62.7% reduction in Denials (exceeded goal)

• 63.3% ($4.1M) reduction in denial total charges

• $703K in Labor Savings (9 FTEs reallocated)

• Trained 2 Subject Matter Experts in lean tools

5

Results

RIE = Rapid Improvement Event aka Kaizen event

ROI of 10.1x

PeriOp Case Study

•Delayed/late cases, low productivity, excess & obsolete supplies

• Variation in patient prep RN to RN, missing

• Significant wait time for lab results

• Inconsistent process to pull and charge for supplies

• Excessive room changeover times

6

Situation Summary

• Identify long range plan for lean implementation with clear business results defined: •Improve operational efficiency•Improve patient safety and outcomes •Improve patient satisfaction scores•Improve quality of work life •Improve financial performance

• Improve contribution margin by improving OR utilization

7

Client Objectives

Road Map

Data Prepared Surgical Service VSM Event

VS Owner John Brothers

Team Leader Robin Luehr/Dana Troutman

Data Prepared 6/15/2012

#Action - SYSTEM

EventsWhere

Event

Type

Potential

LeaderExpected Results

1

Improve Data flow and collection.

Non-standard metrics.

Improve accuracy and consistency

of data. (Definitions)

BI, OR, IT SW John Brothers

Standardized Process for compiling OR data.

Develop standardized metrics of measurement for all 3 campuses

Standardize process for compiling data - datasource, definitions

Understand the reporting forums. Have standardized metrics and targets

shared by all 3 hospitals.

Identify metrics for Patient Satisfaction, Quality, Quality of Worklife and

Financial Performance

2

IT System Analysis for OR

Multiple Information Systems

utilized in the OR/Surgical

Services (different systems utilized

at the campuses)

OR Just do it John Brothers

Understanding OR systems: What does future state look like for it?

(Decrease in systems)

Patient Satisfaction, Improve outcomes, Quality of Work Life, Financial

performance.

3Scheduling/Requesting key

information/Block TimeOR SW John Brothers

Standardization of scheduling and key information needed (process & IT)

Eliminate redundancy of requesting physician orders multiple times

Review Block Time Utilization/Improve OR Utilization

Goal is to improve unused Block Time by 25%

Patient Satisfaction, Improve outcomes, Quality of Work Life, Financial

performance.

4Patient has multiple registrations

preparing for OR

Registration

sSW John Brothers

Can we reduce #/registrations? Pre- reg?

Create Standard Work for Registration

Patient Satisfaction, Improve outcomes, Quality of Work Life, Financial

performance.

5

Results Realization Check: Verify

that intended results-to-date have

been realized and endorsed by local

leadership

Administratio

nR2K Site COO/CFO

Validate realization of desired performance improvement results. If not,

conduct 2-3 day Results Realization Rapid Cycle Improvement Event before

proceeding with any further rapid cycle improvement events

6Pre-Anesthesia/Pre-OP/non-

standardized

Pre-

Anesth../

Pre- Op

Testing

SW John Brothers

Standardize what patients need to come to the hospital for a pre-

anesthesia visit

Standardize information required.

Eliminate/Reduce duplicative testing (lab testing done in the physician's

office, repeated in Pre-Anesthesia testing, H&P's)

Clear roles and responsibilities.

Develop process for some testing to be completed on the morning of OR.

Standardize Pre-Anesthesia orders/criteria

Decrease motion and transportation within hospital

Patient Satisfaction, Improve outcomes, Quality of Work Life, Financial

performance.

VALUE STREAM ROAD MAP

Value Stream Map

• Pilot hospital – typical start in large hospital

• Then roll out to regional hospitals and rural critical care centers8

Approach

• $3.4 million increased capacity in the Operating Room

• $1.9 million increased contribution margin at largest campus by improving OR utilization

• 17% operational throughput for Same Day Surgery

• $50,000 reduction in obsolete inventory

• $53,600 reduction in overtime & staff turnover

9

Results

ROI of > 10x

Emergency Department Case Study

•Patient dissatisfaction, long wait times, inconsistent processes, poor interdepartmental communication• High LWOT – patients dissatisfied and leave before treatment

• Lack of standard work for staff & nurse protocols

• Door to Doctor time & Doctor to Unit time too long

• Variation in patient prep RN to RN

• Significant wait times for lab results

10

Situation Summary

•Improve patient flow with reduced wait times

•Improve visit outcomes with fewer LWOTs

•Improve process with standardized patient care processes

•Improve patient satisfaction with staff-patient interactions

11

Client Objectives

Road Map

Value Stream Map

Net Revenue

per visit

Annual Net

Revenue

Decrease LWOTS 1,000

Level 5 380 $31 $11,780

Level 4 450 $88 $39,600

Level 3 170 $231 $39,270

Annual Net revenue From ED $90,650

Expected Admits from LWOTS 8%

Estimated additional Admits 80

Net revenue per Admit 8,945 $715,604

Total increase in Net Revenue $806,254

Reduce S&T transfer by 10 per month 120

Net Revenue per admit 8,945 $1,073,406

Reduce Re-admits by 25% 72

Impact to penalty 2,986 $215,000

Decrease LAB TAT 25% 8532

Additional Studies anually 1,280 31.65 $40,506

TOTAL $2,135,166

Future StateCurrent State VSM

• Started in main 275 bed/29,000 annual ED visit hospital

12

Approach

Value Stream Mapping:

Emergency Department

Identifying

Diagnosing & Prioritizing

opportunities

Quantifying the benefits

Creating a plan

RIE –

Triage & Registration

Standard Work

RIE –

Door to Doc & Admit

time

RIE –

Lab standard work for

results

RIE –

RN std wk (transfer,

admits,handoff)

Changing the process.

Engaging the people.

Realizing the results

5 Months

ED Transformation Road Map w/RIEs

(Rapid Improvement Events)

• Overall $2,100,000 improved financial performance

• $800,000 decreased LWOT, increased admissions (included above)

• 44% reduction in average door to doc time (27 min to 15 min)

• 25% Lab TAT ($40k) reduction in lab result turnaround time & subsequent increased studies

13

Results

ROI of > 13x

Patient Flow Case Study

•Patient dissatisfaction regarding discharge. Slow flow through diagnosis & test processes• Up to a four hour wait for discharge after orders are written

• Long wait times for short procedures – staff “searches” for patients

• Lack of standard work for nurses and duplicate systems create waste

14

Situation Summary

• Improve patient experience

• Reduce Length of Stay

• Reduce LWOTs

• Increase capacity to support more revenue

• Standardize the discharge process

15

Client Objectives

Current State understanding

Action plan and ChartersSJRMC Admit to Discharge VSM

Action Step/ Kaizen Events Owner Event Dates Status Benefits

Problem: We rely on 2-way communication for all communication, no

way to prioritize calls. Actions: 1. Analyze call volume / sources /

content. 2. Establish Physician rounding schedules (SEE ITEM 6), 3.

Investigate Communication Systems - (pager?) 4. Review Nurse initiated

protocols - k+, mag. 5. Reduce calls from / to areas (SEE ITEM 7). 6.

Increase implementation of Responder 5. 7. Educate all staff to think "Is

this call necessary?" before it is made. 8. Review Housekeeping

process. 9. Paging Standard Work.

CindyKaizen (TPI /

SW)8-15 to 8-19

25% reduction in minutes spent on Phone, increase pt.

Satisfaction, increase staff Satisfaction (Combine with 7)

Problem: Multiple incoming calls interrupting Pt care and nursing tasks.

Actions: 1. Id Source and reason for calls, 2. Identify calls that need to

be handled by RN (immediate, return call), 3. Obtain IT report - # of calls

/ minutes spent per shift. 4. Create standard work for Unit Secretaries

Communication

Kaizen (SEE 3)

25% reduction in minutes spent on Phone, increase pt.

Satisfaction, increase staff Satisfaction (Combine with 3)

Problem: Lack of consistency in rounding times can delay discharge,

and delay care and increase phone calls (SEE 7 and 3). Actions: 1.

Assess Rounding routines by group and specialty 2. Research bylaws

for rounding (1X per day). 3. Determine Cost of avoidable days /

Revenue capture. 4. Set a standard (goal) time for Discharge Orders.

5.Educate / monitor for improvement.

Kaizen(TPI/SW)Improve pt. Satisfaction, Improve discharge time, Improved

coordination, Improved patient safety, Decrease LOS.

Problem: Incorrect patient status / information entered into Meditech,

resulting in missed revenue and unnecessary communication loops.

Action Steps: 1. Root Cause analysis - Why is this happening? 2.

Review Access Nurse - MRN communication Process, 3. Implement Fix

Theresa Kaizen (SW) TBD Improve revenue capture.

Problem: Nurse delaying discharge even if all other processes are in

place and complete. Actions: 1. Root Cause Analysis (perception vs.

reality), 2. Define Standard Time to discharge / Steps to take (Standard

Work), 3. Gap to Standard Analysis. 4. Re-work process to eliminate

and re-address incentives and disincentives of the process. 5. Educate

/ Apply resources to optimize process efficiency. 6. Set up structure for

data collection / monitor data over time.

Megan Kaizen (SW) 7/18-7/22

Decrease Order to Discharge time - (Target 2 hours), Increase

Pt. Satisfaction (HCAPS), Increase throughput (decrease

boarders / holding patients), Increase Staff Satisfaction

(Turnover Reduction).

Problem: Relocation of Pt. takes time and resources Actions: Quantify

impact, do RCA, ID trends (units, seasonality etc.) Develop

countermeasures, Standardize Process. Address physician preference

issues.

HeatherMeeting /

Project1-Sep

Decrease time spent turning rooms, improve safety, decrease

supply cost, decrease cost of care.

Problem: Delays in entering pt status (ADT) on admission/transfer/DC

causes a delay in PT care, and room readiness for next pt. Actions: 1)

Define timeframes/expectations on when ADT is completed 2) Educate

staff on expectations, 3. Develop report to monitor ADT times. Educate

leaders to run report, Hold Staff accountable.

Karen Meeting / JDI 1-AugImprove room turnover times (26% failure Currently - Target <

10%), Eliminate delays to patient care.

Problem: Stocking Pyxis during peak med Admin times 0900 - 1400 -

2100 - 0600 delays med delivery. Action: Review current Pharmacy /

Materials Schedule for stocking, review staffing of pharmacy / Materials,

(Align pharmacy / Materials schedule to med delivery schedule).

Investigate options (mini pyxsis) 5) re-inforce Red-Zone / Quiet Zone, 6)

Review policy and Procedure for timeframe to Admin Meds 7) A

message to Pharmacy for 1st Doses, Out of stock, needed

Kim Meeting(s) 31-JulDecrease calls, smoother workflow, eliminate delays to care -

waiting for Pharm, increase Safey,

Problem: Excess Motion and time primarily nursing. Actions: Root

Cause analysis to find excess motion - extra physical steps for care and

supplies, 2. Physical mapping of South and North Pods / Central Pods.

3. Standardize Pyxis (Supply and Meds), 4. Identify biggest impact

areas, Develop countermeasures, re-map

Terry Project 1-Oct

Improve Staff Satisfaction, Improve efficiency, Safety - able to find

tools, Improve patient satisfaction, Big impact on short stays.

Decrease steps in a day.

Problem:We spend too much time logging into computers, causing

delays in care Solving: Implement solution being used in ED.Cindy JDI Dec-16

Improve Employee satisfaction, decrease time to dispense

medication, decrease wasted time.

Problem: Discharge instructions (education) are hard to follow /

understand. Actions: Can Revisions be made to format?, Review format

/ layout of Discharge Summary, Develop Alternative format, Test

formats, Take product to Clinical Informatics.

Becky Project 1-Nov

Improved pt. understanding, Decrease re-admissions,

decrease phone calls backs, decrease time spent on

discharge, Patient awareness of follow-ups.

Problem: Long registration process can delay care / throw off schedules

for procedural areas. Action Steps: 1. Review screens to see if there is

any opportunity (Why doesn't information copy over from registration to

Nursing Admission Summary?), 2. Evaluate what we are currently doing

and what is required. 3. Investigate online registration. 4. Clarify

signage at Registration. 5. Map Reg Process for procedural areas. 6.

Simplify and Clarify process / paperwork.

Theresa Project 1-NovImprove HCAP scores, Reduce Pt. confusion, reduce reg times,

reduce patient motion.

Problem: Obs. Status Stays are treated the same as inpatients leading

to going over OBS hours and loss of revenue. Action Steps: 0.

Understand commonality among observation stays / trending for

potential standardization of care. 1. Tier Priorities for ancillary studies

(Lab Best Practices?). 2. Promote a cultural shift of obs status

Dr. Greenberg Kaizen (TPI)11/14 -

11/18

Increase throughput, Increase Revenue, Evidence based care,

Patients will not suffer financially (Bill Issues), Less Administrative

Overprocessing, Clarity for case RN managing = Less Rework,

Less Time delays + obs hours @SJRMC, Less confusion among

staff, Accountability and enhanced case protocols, Pt and Staff

Problem: two processes exsist for provider orders resulting in errors and

increased time spent processing and clarifying orders. Actions: 1.

Track errors based on CPOE vs handwritten orders. 2. Revise Quantros

investigation report to include CPOE vs. or handwritten. 3. Investigate

voice recognition CPOE. 4) Quantify provider time saved by using

CPOE? 5) Continue to document and quantify impact on Nursing

Dr. Hoffman Project Dec-16Decrease Order entry errors, decrease sime spent clarifying and

transcribing orders, Improve NSG / Staff / Satisfaction

Problem: Documentation quality is poor - (unclear, incomplete, lacks

depth, is not timely) creates additional work, causes delays in care,

makes us look bad, leads to a loss in revenue, can cause safety issues.

Actions to Solve: 1. Review what standards exist today. 1a, Priortize

groups based quality issues. 2. Further clarify documentation

requirements - Supplier and Customer perspectives. 3. Agreement on

"new" standards. 4. Educate and Sustain "new" standards.

GingerTPI (Quality)

Kaizen

12/19 -

12/23

Improve communication, throughput, increase resiliancy to

medical necessity denials, improve revenue. Reduce LOS by 1

day. Improve compliance with regulatory agencies.

Problem: Patient has to wait at various times during their hospitalization.

Action Steps: 1. Identify wait times and locations. 2. RCA on extended

wait times. 3. Clarify Patient expectations 4. Develop scripting for staff

5. Improve patient communication / education. 6. Schedule times for

follow-up 7. Improve communication between departments.

Dawn Project 31-Oct

Decrease wait times, increase patient satisfaction (HCAPS).

Increased employee satisfaction (EOS). Improved communication

inter department communication. Decrease in Service

Complaints.

Problem: Multiple computer systems lead to fragmented patient care

and lost records Actions: Assess current State, Can we eliminate /

improve current systems?, Identify, eliminate/mitigate navigation wastes,

duplicate information entry, (create clinically relevant default PCI tab),

Implement and Educate on changes.

CammieMeeting to

determine Proj /

Kaizen

1-AugImprove Staff Satisfaction, Save time, increase efficiency,

Improve patient Safety, improve continuity of care

Create VSM / Improvement Roadmap to Improve time it takes to

discharge a patientVSM 6/20-6/24

Identify road map to improve time to discharge. Target a XX%

Improvement.

Improvements made need to be sustained / improved. Implement Lean

Daily Management - select 5 impacted departments and develop LDM

process and KPI boards

Kaizen (LDM) TBD

Validate Results realization - R2K - review results 60-90 days after

KaizenR2K 10/15/2016

• Client was 70 bed for-profit hospital

16

Approach

• $390,000 incremental revenue in Radiology (5 more cases/day)

• 50% reduction in lead time: order to discharge

• Reduced LOS by 1 day

• $20,000 new lab cost avoidance and $8k supply savings

• 38% Registration Productivity increase

17

Results

ROI of > 8x