transformation of a service operations system through lean process improvement

Behavioral Operations -2011, © Linda LaGanga, 2011 1

Transformation of a Service Operations System through Lean Process Improvement and Learning

CollaborationBehavioral Operations

Management Conference, INSEAD Business School,

Fontainebleau, France, June, 2011

Linda LaGanga, Ph.D., LPCDirector of Quality Systems &

Operational ExcellenceMental Health Center of Denver

Denver, CO, [email protected]

Additional information available at:https://secure.smhcd.org/OutcomesPubs.aspx

Behavioral Operations -2011, © Linda LaGanga, 2011

What’s this Action Research about?• Healthcare Service Operations Systems

– Configure– Deliver– Measure– Improve

• The Continuum of Healthcare• Lean Transformation and Learning Collaboration in Inpatient to Outpatient Settings

• Timeliness in Access to Care• The Lean Paradox


Research in Improving Outpatient Healthcare Operations

Appointment Scheduling

Lean Process Improvement CQI

Decision utility model, To overbook or notLaGanga & Lawrence (2007, DSJ)

Action research,Empirical case studyLaGanga (2011, JOM)

Interviews and pilot surveysKovach, Fredendall, LaGanga) (2011, DSI)

Presentation Objective: • Position Action Research with several

methodologies & philosophies• Consider areas of research interest in Behavioral

Ops Management

Capacity Expansion Process Improvement


The 2‐Dimensional Continuum of Healthcare

4

Inpatient Services / Emergency Department Outpatient Services

Mental Health / Behavioral Health

Physical Health


First Healthcare Delivery Organization Wins Shingo Prize in 2011

• Denver Health winsfor Lean Systems Improvement

• Denver Health executives estimate the program saved $88 million in operational expenses

• Helped safeguard all 5,500 Denver Health jobs. • Even in a poor economy, didn’t have to cut care for the city's uninsured and underserved.

• Auge, Denver Post, 3/23/11, “Denver Health Wins International Award for Efficiency.”

5


Lean Transition to Outpatient Settings• Hospitals to Outpatient

– Clinics run by hospitals– Collaborating outpatient systems

• Outpatient Community Mental Health Center– Expand Access– Reduce Process times– Streamline documentation– Coordinate care– Improve treatment planning– Enhance funding

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Language and Values

• Applying manufacturing principle to health and human services

• “Our product is people”• Measure and report what people understand and value

• Productivity

• “Consumer Service Hours”


Value: Enhance Funding and Treatment Outcomes

• Healthcare Funding• Process Measures

– Counting– Compliance

• Service Effectiveness– Outcomes Measures– Throughput to serve more people– Community impact– Cost effectiveness


Stretch Your Dollar

$ The Mental Health Center of Denver admitted 400 new adults with serious mental illness into high intensity services the first year of implementation of its Recovery Needs Level instrument with no additional resources.

$ Based on a cost of $12,500 per consumer

= Total public cost saving annually is $5 Million.

Reaching Recovery, © 2011


Court to Community Treatment Outcomes• After 18 months:• 2/3 Have Not Been Re‐Arrested• 80% Reduction in Jail Time• $104,790 Savings to Taxpayers

N =1873

N = 376

0

400

800

1200

1600

2000

Pre Post

# Jail Days

Admission Period

Change in # of Jail Days: All Clients

80% Reduction


Example of a Lean Improvement Project and the Continuum of Care

• Coordinated and Integrated Healthcare Services• Motivation for Lean Improvement :

Reduce Emergency Room and inpatient use in Behavioral Health Setting

• Goals: – 25% reduction of Medicaid‐funded inpatient costs for Behavioral

Healthcare for calendar year 2010 – Increased collaboration between inpatient and outpatient

providers. – Increased financial resources for outpatient services. – Availability of correct level of service when needed


Measures and Sources• Claims data

– Hospital admission rates– Average length of stay– Emergency Room utilization– Hospital recidivism– Follow‐up rates after discharge

• External benchmarking against other managed care organizations

• Outpatient admissions – Call center data– Electronic Medical Record– Service Requests– Admissions– Time to appointments– Show rates

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Key Lean Project• Timeliness In Access to Care• Rapid Improvement Capacity Expansion (RICE)

– Concentrated on Appointment Allocation/Assignment Process– Shifting and increasing appointment availability– Increasing Show Rate– Matching interactions to consumer needs

• LaGanga, 2011. Lean Service Operations: Reflections and New Directions for Capacity Expansion in Outpatient Clinics. Journal of Operations Management 29(5).

• Research started as appointment scheduling models for no‐shows and overbooking; evolved to lean focus.

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Receive call from consumer Consumer not

admitted. Exits but may call again.

Clinical Intake TeamsAccess Center

Consumers Seeking Access

Match consumer to appointment

slot and remove appointment

from inventory of available

appointments

Consumergiven anIntake

appointment.

Monday

Tuesday

Wednesday

Thursday

Friday

Release appointments to days of the scheduling week

No slots available or no appropriate

match for consumer

Consumerexits, waits

for Intake

appointment.

Inventory of Appointments

CustomerSupplier

Check appointment inventory for availability

Configuration of Appointment Allocation System


Consumers ProvidersOrientation

IndividualIntake Assessment



Delay (Days) Consumer leaves and doesn’t return

Idle IntakeClinician due to consumer no-show

Delay (Days) Consumer leaves and doesn’t return

Idle Psychiatrists due to consumer no-shows

IndividualPsychiatric Evaluation



OrientationOrientation

Orientation

Exit: Completed Intakes

Intake Process: Before Lean Improvement


Consumers Providers

IndividualIntake AssessmentIndividual

Intake AssessmentIndividual

Intake Assessment

Orientation

Overbooked consumer who shows up


Clinician called into service for overbooked consumer who showed up

Intake Process: After Lean Improvement


Consumers Providers

Orientation




Delay (Days)

Consumer leaves and doesn’t return


Delay (Days)

Consumer leaves and doesn’t return

Idle Psychiatrists due to consumer no-shows




Orientation Orientatio

n Orientation

Exit: Completed Intakes

Consumers Providers




Orientation

Overbooked consumer who shows up


Clinician called into service for overbooked consumer who showed up

Intake ProcessBefore and After


Appointments scheduled and no‐show rates before and after lean improvement

Appointments Scheduled

0100200300400500

Mon Tue Wed Thu Fri

Before

After

No-Show Rates

0%

5%

10%

15%

20%

Mon Tue Wed Thu Fri

Before

After


Lean Process Improvement: One Year AfterRapid Improvement Capacity Expansion

RICE Results• Analysis of the1,726 intake appointments for the one year before and the full year after the lean project

• 27% increase in service capacity– from 703 to 890 kept appointments) to intake new consumers

• 12% reduction in the no‐show rate– from 14% to 2% no‐show

• Capacity increase of 187 additional people who were able to access needed services, without increasing staff or other expenses for these services

• 93 fewer no‐shows for intake appointments during the first full year of RICE improved operations.

• Annual cost savings (expense avoidance):$90,000 ‐ $100,000 for staffing and space


Improvement in accessibility and timely access to services based on service value in lean outpatient health care (based on Womack and Jones, 2005). Before

Consumer’s steps and time for admission to services, before lean process improvement.

Time Step likely to recur?

1. Call Access Center for admission to services. 10 minutes Yes

2. No slot available. Wait to call again. 3 days ‐1 week Yes


4. Possible slot available. Provide more assessment information. 15 minutes Yes

5. No appropriate slot available. Wait to call again. 3 days ‐1 week Yes

6. Call Access Center for admission to services. Provide more assessment information. Appropriate slot obtained. Appointments made for orientation and intake assessment.

30 minutes. No

7. Wait for orientation. 1 – 7 days. No

8. Orientation for paperwork, explanation of policies and procedures. 50 minutes No

9. Wait for Intake Assessment session. 1 – 7 days. No

10. Intake Assessment session with individual clinician. 60‐90 minutes. No

Total time (minimum possible) 2 days + 140 minutes

Total time (maximum if consumer is admitted on 4th call) 5 weeks 245 minutes

Actual clinical service time (value‐creating time) 60‐90 minutes

Total steps with recurrent steps 14

Behavioral Operations -2011, © Linda LaGanga, 2011 POMS-2011, Linda ©22

Improvement in accessibility and timely access to services after Lean Improvement

Consumer’s steps and time for admission to services, after lean process improvement.

Time Step likely to recur?


2. No slot available. Wait to call again. 1 – 3 days Yes


4. Possible slot available. Provide more assessment information. 15 minutes Yes

5. No appropriate slot available. Wait to call again. 1 – 3 days Yes

6. Call Access Center for admission to services. Provide more assessment information. Appropriate slot obtained. Appointment made for orientation and sequential intake assessment.

30 minutes. No

7. Wait for Intake clinician to call and welcome. 1-3 days No

8. Talk to Intake clinician about appointment. 10 minutes No

7. Wait for orientation. 1 day No

8. Group Orientation for paperwork, explanation of policies and procedures. 40 minutes No

10. Intake Assessment session with individual clinician. 60-90 minutes. No

Total time (minimum possible) 2 days + 140 minutes

Total time (maximum if consumer is admitted on 3rd call) 1 week + 190 minutes

Actual clinical service time (value-creating time) 70-100 minutes

Total steps with recurrent steps 12


Comparing process steps: Before and After• Before:

• Total steps with recurrent steps (worst case with 3 instances of steps 4 and 5) = 3 x 3 + 5 = 14

• After• Total steps with recurrent steps (worst case with 2 instances of steps 4 and 5) = 2 x 3 + 6 = 12

• Eliminates 2 steps


Comparing process time and lag time:

• Before: • Total time (minimum possible) = (30+50+60 minutes) + 2 days = 2 days 2 hours and 20 minutes

• Total time (maximum if consumer is admitted on 4th call) • = 5 weeks 4 hours and 5 minutes

• After:• Total time (minimum possible) = Same as above• Total time (maximum if consumer is admitted on 3rd call) • = 1 week 3 hours and 10 minutes

• Process and lag time reduction of worst case:• > 4 weeks


Process Improvement• Accomplished by involving clinicians and consumers• Reconfiguration for timely and consumer‐friendly access

• Measured– Increased intakes– Decreased no‐show rates– Decreased delays to access

• Multi‐dimensional impacts (projections)– Reduced inpatient expenses– Physical/Behavioral dimensions of healthcare

• Transition• Transformation


What is the Lean Paradox?

• Just‐in‐time?– NO

• New Bottlenecks?– YES

• Rapid Improvement?– NOT!

• Solutions– Clear out project clutter– Prioritize– Realign project scheduling

• Sustainability and human behavior

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Transformation of a Service Operations System through Lean Process Improvement and Learning

Collaboration

Behavioral Operations Management Conference, INSEAD Business School,

Fontainebleau, France, June, 2011Linda LaGanga, Ph.D.

Director of Quality Systems & Operational Excellence

Mental Health Center of DenverDenver, CO, USA

[email protected] information available at:https://secure.smhcd.org/OutcomesPubs.aspx

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