MHCD’s Lean Process Improvement Program in Clinical Outpatient Mental Health Services

1. Lean Process Improvement in
Outpatient Clinics
Decision Sciences Institute Annual Meeting
New Orleans, Louisiana – November 15, 2009
Linda LaGanga, Ph.D.
Director of Quality Systems & Operational Excellence
Mental Health Center of Denver
Denver, CO, USA
Additional information available at:
http://www.outcomesmhcd.com/Pubs.htm
http://Leeds.colorado.edu/ApptSched © 2009 – Linda LaGanga
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DSI 2009 – New Orleans © 2008 – Linda LaGanga and Stephen Lawrence
2009

2. Agenda
1. Background on
the Organization
2. Lean Approaches
3. The Lean Improvement Projects
4. Insights and Recommendations
5. Contributions and Future Directions
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2009

3. 1. Background on
the Organization
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4. The Mental Health Center of Denver
(MHCD) is a private, not-for-profit,
501 (c) (3), community mental health care
organization
Providing comprehensive, recovery-focused
services to more than 11,500 residents in the
Denver metro area each year. Founded in 1989,
MHCD is Colorado’s leading provider and key
health care partner in the delivery of outcomes-
based mental health services.
“Enriching lives and minds by focusing on
strengths and recovery.” 4
DSI 2009 – New Orleans © 2008 – Linda LaGanga
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5. MHCD Recent Innovation Awards
Effective Programs
The U.S Department of Health and Human Services Substance Abuse and
Mental Health Services Administration (SAMHSA)
Science to Service Award 2009
GROW (Growth and Recovery Opportunities for Women) program.
Evidence-based interventions shown to prevent and/or treat mental illnesses
and substance abuse.
Read more at http://www.samhsa.gov/scienceandservice/cod2009.aspx.
Efficient Systems
Our Lean Process Improvement in Outpatient Healthcare Project won
recognition of the Colorado Behavioral Healthcare Council (CBHC) and received
the 2009 Golden Abacus Award for Best practices in the Non-Clinical Arena
www.cbhc.org.
Environment Leadership
MHCD and its Together Green Team were nominated by the Governor’s Energy
Office for a Colorado Environmental Leadership Program and were named a
Bronze Award winner for its commitment to environmental leadership. Visit
http://www.cdphe.state.co.us/oeis/elp/index.html
Awards based on measurable results and outcomes
Services, Evaluation & Research, Quality & Operational Excellence
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6. Healthcare: Research
and Operational Excellence
Accountability
Tracking and data availability
Outcomes
Quality management
Efficiency
Effectiveness
Evidence-based practices
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
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7. Research Capacity
Clinical and Rehabilitation Service
Effectiveness
Quality Systems & Operational Excellence
Ph.D. Staff: 4 + 1 Ph.D. Candidate
OR, Statistics, Psychology
Master-level Licensed / Certified Clinicians
Evaluation & Research Team
Sponsor and analysis of Lean Process
Improvement
Action Research
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
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8. Action Research
“Research in action, rather than research about action;
participative; concurrent with action; a sequence of
events and an approach to problem solving.” (Coughlan
and Coghlan, 2002)
Field study situation in which there was active
communicating with practitioners, reporters, and the
public in response to the initial study (LaGanga and
Lawrence, 2007 & 2008)
Concurrently applying the emerging recommendations
and insights to a real change process -- the lean
process improvement program
The author was a direct sponsor and active participant
in solving an operational problem and effecting change
in an actual organization
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
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9. 2. Lean Approaches
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
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10. Motivation
Healthcare Capacity
Funding restrictions
Demand exceeds supply
Serve more people with limited resources
Manufacturing Scheduling
Resource utilization
Maximize throughput
Healthcare Scheduling as the point of
access
Maximize appointment yield
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
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11. 2007 Consumer Reports survey of 39,000 patients
and 335 primary care doctors (Hitti, 2007)
Top patient complaint was about time spent
in the waiting room (24% of patients)
Followed by 19% of patients who complained
that they couldn’t get an appointment within a
week
Fifty-nine percent of doctors in the survey
complained that patients did not follow
prescribed treatment and 41% complained
that patients waited too long to schedule
appointments.
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

12. Literature: Access to Healthcare
Institute of Medicine (2001)
Crossing the quality chasm: A new health system
for the 21st century.
Murray & Berwick (2003)
Advanced access: Reducing waiting and delays in
primary care. Journal of the American Medical
Association, 289(8).
Green, Savin, & Murray (2007)
Providing timely access to care: What is the right
patient panel size? The Joint Commission Journal
on Quality and Patient Safety, 33(4).
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
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13. Lean Approaches
Reducing Waste
Underutilization
Overtime
No-shows
Patient Wait time
Customer Service
Choice
Service Quality
Outcomes
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
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14. Lean Process Improvement in Healthcare
Documented success in hospitals
ThedaCare, Wisconsin
Prairie Lakes, South Dakota
Virginia Mason, Seattle
University of Pittsburgh Medical Center
Denver Health Medical Center
Influences
Toyota Production System
Ritz Carleton
Disney
Hospitals to Outpatient
Clinics run by hospitals
Collaborating outpatient systems
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15. 3. Lean Projects
Lean Process Facilitator and Sponsor at
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16. Field Work: Interviews
Lean Event Process at the Mental Health Center of Denver
11/14/2009 Kovach & Fredendall - DSI 16
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17. Lean Projects Overview
Rapid Improvement Capacity Expansion
Express Intake
Human Resources Hiring Process
Grants Financial Management
New Clinician Training
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
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18. First Lean Project
Rapid Improvement Capacity Expansion (RICE) Team
January, 2008
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
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19. Lean Process Improvement: One Year After
Rapid 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 (avoidance):
$90,000 - $100,000 for staffing and space
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
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20. Lean Process Improvement:
RICE Project System Transformation
Appointments Scheduled
and No-Show Rates
450 20%
400
Appointments
350 15%
300
250
10%
200
150
100 5%
50
0 0%
Mon Tue Wed Thu Fri Mon Tue Wed Thu Fri
Year Before Year After
Lean Improvement Lean Improvement Appointments
No-Show Rate
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

21. How was this shift accomplished?
Day of the week: shifted and added
Tuesdays and Thursdays
Welcome call the day before
Transportation and other information
Consolidated steps
Orientation to Intake Assessment
Eliminated an opportunity for no-show
Group intakes
Overbooking
Flexible capacity
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

22. Lean Scheduling Challenge
Choice versus Certainty
Variability versus Predictability
Sources of Uncertainty / Variability
No-shows
Service duration
Customer (patients’) Demand
Time is a significant factor
Airline booking models?
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23. Second Lean Project
Express Intake Team
August, 2008
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
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24. Motivation for Fast Track Intake
More rapid access to targeted populations
Special grants and contract funding
No state CCAR needed
7 pages
25 outcome domains
Scarcity of intake appointment slots
Lengthy intake process
Average 2.07 hours
Many forms
17 for adults
19 for children/adolescents
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
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25. Current State (Before Lean Event)
Approximately 2/3 seeking services turned
away
If admitted, up to two week wait for intake
appointment
All slots filled early in the week
Three or more staff required
Access center clinical / call taker
MIS staff
Intake clinician
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

26. Target State
Provide high-quality services
Provide access to more people seeking
services
Start service delivery promptly
Match work time to reimbursement rate
Positive consumer experience
Valuable clinical outcomes
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
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27. Gaps
Treatment delays
Perception that center is not accessible
Inadequate reimbursement
Redundant data collection
Unnecessary work and data collection
Errors in recording and processing data
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
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28. Solutions
Identify appropriate payer/contract sources
Identify value-added intake information
Reduced data items/forms from 17 (or 19)
to 4
No state CCAR outcome form
Focus on appropriate outcome measures
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

29. Solutions
Bypass Access Team
Direct to designated clinicians
Continuity of care
Contact & Triage form
Halved from 4 to 2 pages
Completed by clinicians
Eliminate waiting for MIS staff to complete form
Use for all new intakes, not just special grants and
contracts
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

30. Electronic Health Record
Opportunities to streamline clinical work flow
Improve quality of care
Structures and standardizes work processes
Menus
Programmed logic and forms
Data validation and feedback
Lean Paradox
Bottleneck in programming
Implementation delays in some projects
New forms and intake processes within 90 days
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

31. Results with Department of Corrections
Prison parolees
Rate of intakes tripled
Duration appeared unchanged
Standard versus actual time recorded
3 hours > 2.07 average of other clinicians
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

32. Lean Process Improvement: (First 3 months)
Express Intake: Fast Track Project
Clinician Time to do Intake
70%
60%
50%
Cases
40%
30%
20%
10%
0%
0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00
Before Fast Track Hours
After Fast Track
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

33. Summary of Results
In the first three months of operation, the average
service time decreased from 2.06 to 1.98 hours
Effect small but significant (p < .05).
More encouraging is the change in the distribution of
service time,
Percentage of total intakes that were completed
within two hours increased from 67.5% to 75%
so the percentage of intakes exceeding two hours
decreased from 32.5% to 25%.
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

34. Results
Service times shortening
Decreased range and variability
Room for more intakes
Increased access to services
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

35. Other Efficiencies
Elimination of “Hidden factory” of MIS
Not captured in EHR system
Data entry
Checking and correcting clinician errors
Not visible in productivity measures
More profitable enrollment
Ensure correct billing to appropriate payers
Appropriate outcome measures
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

36. Third Lean Project
Human Resources Hiring Project
October, 2008
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

37. Hiring: Improving a Business Process
Delays and bottlenecks in communication
Automated communication
Built on Electronic Health Record
Required systems analysis and programming
Six months to implement
Reduced time to fill positions by 3 days
Harder to measure than clinical improvement
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

38. Fourth Lean Project
Grants Financial Management Team
December, 2008
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
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39. Financial Management:
A Business Process
Initial state: Lack of feedback and reporting
Requires technology and programming
About a year to implement
Dependent on completion of prior lean project
for staff tracking and allocation
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

40. Fifth Lean Project
New Clinician Training Team
January, 2009
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
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41. New Clinician Training:
A Business Process
Target State: Clinicians trained to be productive
within 3 days of hire
Job requires use of Electronic Health Record
Quickly determined how to achieve target
Designed new training program
Implemented initial computer training within 1
month
Development of on-line training modules:
Little progress due to other staff commitments
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

42. 4. Insights and Recommendations
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
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43. The Right People
Talents
Credibility
Stakeholders
Ownership
Motivation
“People are our product”
What’s in it for me?
“Why am I being punished?”
“Can I come back tomorrow, too?”
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

44. The Right Problems
The first project was a perfect fit
Immediate change
Energized and committed participants
Technology was valuable for measurement
Didn’t require reprogramming EHR
Success fueled interest
Not everything could or should be a lean
project
Lean paradox
Bottlenecks
Rapid improvement: Not!
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

45. The Lean Paradox:
Projects by Functional Area
Electronic Health Record
Programming and Enhancements
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

46. Project Management
and Organizational Discipline
Assigning ownership and follow-through
Critical mass
Project management systems
Selective about lean projects
Improving measurement processes
Working on financial analysis
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

47. 7. Contributions &
Future Directions
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

48. Contributions
Outpatient services crucial to cost-effective
healthcare delivery
Lots of hospital research but little in outpatient
Lean can greatly expand direct service capacity
Room to leverage lean outpatient business
process improvement
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

49. Future Work
Ongoing analysis and improvement of lean
approaches
Continued action research on Quality
Improvement in outpatient settings
Lean Learning Collaborative
Find other outpatient organization using lean
Gather and share ideas through on-line group
Lean Leaders and Catalysts for Improvement on LinkedIn
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DSI 2009 – New Orleans © 2008 – Linda LaGanga
2009

50. Questions? Comments? Discussion?
Lean Process Improvement in
Outpatient Clinics
Decision Sciences Institute Annual Meeting
New Orleans, Louisiana – November 15, 2009
Linda LaGanga, Ph.D.
Director of Quality Systems & Operational Excellence
Mental Health Center of Denver
Denver, CO, USA
Additional information available at:
http://www.outcomesmhcd.com/pubs/publications.htm
http://Leeds.colorado.edu/ApptSched 50
DSI 2009 – New Orleans © 2008 – Linda LaGanga and Stephen Lawrence
2009