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The Phoenix Project
Integrating Effective Disease Management Into Primary Care Using
Lean Six-Sigma Tools
John Oujiri, MDCynthia Ferrara, MSSt. Mary’s/Duluth Clinic Health System
•Integrated health system
•Main Campus in Duluth,MN with three neighborhood sites
•16 regional clinics throughout northeast MN and northwest WI
•400+ physicians
St. Mary’s/Duluth Clinic Health System (SMDC)
•SMDC clinics are located over 25,000 square
miles and serve a population of nearly half a
million people
•18.7 people per square mile
•11.4% of population below
poverty level (2004)
Develop a standard set of workflows for delivering evidence-based care that provides a consistent clinical experience for patients and a consistent
process for care teams.
Differentiate our organization to payers, employer groups, and government agencies.
Goal of Phoenix Project
Phoenix Lean Process Road Map
8. Control Phase On-goingSustain and Continuous Improvement
7. Staged Implementation Pilot Sites 1-3 Feb 08-July 08
6. Report to Sponsors November 2007
5. Midway Report and Feedback August 2007
4. Sponsor Update Frequent
3. Weekly Action Meetings Start: June 2007
2. 4-Day Breakthrough Work-out June 2007
1. Pre-Launch Planning May 2007
Cross-functional teams from pilot sites (3) assembled to apply lean design concepts to
core processes and systems in four-day event.
Empowered to develop solutions/actions.
Core Breakthrough Team Members: Staff and physicians from pilot sites and key
leadership.
4-Day Breakthrough Work-Out
Breakthrough Design Map
© 2004 Leap Technologies, Inc.
In Between Visit Activities and Pre Visit Planning Sub Process
Big Ideas and Enabling Tools:
PROACTIVE
Schedules interaction v ia:-Call-My Chart-K iosk @ m all- C lin ic K iosk- Home
Telehealth monitors- B/P- CHF-Blood Sugars
•Automated Triggers•Automatically order of needed test as future and & drive work effort (prioritize)•R isk Stratification•Role change of hum an to technology
In tervention is:-Patient Specific-Measurable-Adjusted as needed
-Must be documented v ia email, letter or ?
Previsit Planning- prior to day of, automatic scrubber determ ines needed tests and orders them
Major Process StepsAssum ptions & Open Questions
Assumption: Base of patients a lready ID ’d
Philosophy:Hum an Touch vs. Autom ated
Outside Labs? Appointment
happensCheck out should in ititiate the “in between” process
Combining Med vs. problem list scrubbing
C oordinate v isit with all needed serv ices
Safety Net?
Care Coordinator
Health Alerts
Developed in W orkshop by:•Chris• Mike• Lisa• Dennis• Krister• Karen
Identified Patient Registry
Autom ated reporting & Analys is Tools “C larity on Steroids” business inte lligence tools
Patient Education:•W ebcasts• Podcasts• Link to Comm. Resources• Email• M y Chart
PatientCenter, Not D isease Patient
REACTIVE
What aboutProvider Autonomy?
Out of Care PT
Patient Kiosk:• In C linic• In retail locations• O ther public sites
Integration System:Example: vaccination program
Staff Education and Developm ent:- Scripting
Need to define Com m unity Resources!
Policy/Leadership Decisions:
Key: Standardize protocols and use them as m uch as possible
Create a Problem List and Med List Update Policy
Create a policy on Outside Labs which supports CCSI
? H ospita l or Assisted Living, Nursing Home Pts?
Value Stream Mapping
Demonstrates waste, gaps and major
constraints in care delivery
Identifies value-added steps needed
Captures the current reality
Defines value from customer perspective
Forms the basis for an implementation plan
Major Red Flags Identified• Lack of consistency across clinics in key
sub-processes, roles and workflows
• Under-utilization of EPIC (Electronic Health Record) capabilities and a variety of individual physician solutions rather than a system solution
• Daily mountains of rework by the most constrained resources in Primary Care
• Information Gaps at several critical points in the delivery of Primary Care. Waste identified during encounter and rooming process due to lack of any pre-visit planning
• Significant Patient Activation opportunity
Four guiding principles developed to help move from the current
process to an effective and efficient model of care delivery.
“Do the right thing. Do it right”
Phoenix Guiding Principles
Practice to the full scopeof licensure & abilities
Automate work “That No Human Should Do”
Create and implement a Common Way of Doing Things across the
Duluth Clinic system
Design Centralization into ourprocess wherever it makes sense
Lean Strategies Applied
• Visual Management Use of simple signals and signs in EPIC
• Standardization Work gets done so that the outcomes are more predictable
• Mistake Proofing Building error prevention into the design of the process
• Constraints Analysis / Bottleneck Reduction Improving flow by designing to overcome resource constraints. Move work “forward”
• Automation Taking routine tracking tasks out of the hands of people and into EPIC
Phoenix Primary Care Model Components
Productive Interactions Informed, Activated Patient Prepared, Proactive Practice Team
Pre-Visit Planning Schedule Appointment Review Med List Labs First Scheduled/Ordered Health Maintenance Alerts Between Visit Planning Visit Prep Questions Out-of-range/Out-of-Contact Pts Info from Outside Providers Day of Visit: Rooming Vitals/Rooming Form RN Coaching Med List (Clarify)
BPA based on criteria Load & Pend Refills Initially Diabetic Only Pend BPA’s
Day of Visit: Clinician Check Out Views all data Prints AVS/Med List Reconciliation of Med List Other RN DM Programs Future Appts Patient Instructions/follow-up Warfarin; Diamond; Hypertension Referrals Dx and Orders
PATIENT
Elements of the New Design: Pre-Visit Planning
• Centralized, pre-visit planning takes place for every scheduled visit– Standard process, questions and protocols – Labs ordered per protocol– Health Maintenance alerts
• Initial Med Review takes place before patient appointment
• “Lab First” tasks are completed prior to rooming• A standardized rooming process
(i.e. socks/shoes off for diabetic visits, BP measurement, depression screening)
• Med Review by CA at rooming• Load and pend Best Practice Alerts for
physician order approval
Elements of the New Design: Check-in and Rooming
• Information needed for the encounter has already been prepped for provider
• Provider will:– Reconcile med list– Update Problem List– Make a follow-up appt plan with each visit– Enter future orders– Support patient’s behavior change efforts– Enter patient instructions
Elements of the New Design: Physician/Credentialed Practitioner
• Health risk, knowledge and activation assessment• RN Coaching Model
– Disease coaching and care coordination is a value- added service that payers have been willing to reimburse
– Motivational Interviewing skills• Use of enhanced take-home patient instructions• Creation of a Disease Management Care Plan• EPIC / MyHealth online tools allow patients to
access their medical record, review labs, etc
Elements of the New Design: Patient Activation
• 100% of patients are directed to check out• Every patient receives an After Visit Summary
– Communicates what occurred during the visit Includes instructions and updated Med List
• Next appointment scheduled• Future labs ordered, per provider and protocol
Elements of the New Design: Check-Out
1 23
45
Old
New0
2
4
6
8
10
12
14
16
OldNew
Appears to be “more”
complexity in the front end of
process
These additional up front process tasks
represent “Prevention” of
process rework and delays on the day of
encounter
Process Steps and Perceived Complexity
Process
% of patients with:Completed pre-visit planningHealth Maintenance alerts satisfiedLab orders completeMedication list reviewedRN coaching appointment (per selection criteria)After Visit Summary, Med list and next appt scheduled
Control Phase Key Performance Metrics
*Balanced Scorecard/Strategy Map Measures
Clinical* Optimal Diabetes Management: 25%
Customer Service* Achieve 10% increase in overall patient satisfaction
Financial: Physician and Staff Productivity* RVU’s/Provider FTE* Direct Operating Margin* Encounters per Support Staff FTE
Feedback to Care Teams
Routine reporting feedback loop• Data is provided at physician,clinic and system
level for all SMDC clinics• Incorporates evidence-based guidelines in
assessing quality performance• Process and outcome measurement, evaluation
and management• Data is transparent within the health system
Diabetes Optimal Management % of Patients Meeting All 7 Measures**
Phoenix Project Pilot Site 1 June 07-July 08
n=556
14.6
16.5
15.9
14.8
16.8
19.3
0
5
10
15
20
25
30
35
40
June 07 Sept 07 Dec 07 Mar 08 June 08 July 08Da t e
% o
f pts
with
dia
bete
s m
eetin
g al
l mea
sure
s
Implementation Feb 08
(*) Includes: A1C in last 6 months Blood Pressure <130/80A1C <7% Tobacco FreeLDL in last 12 months Anti-platelet use in patients over 40 y/oLDL <100 mg/dL.
DC-Clinic C Diabetes Management June 2007 – June 2008
n=981
% of Patients with Diabetes with Blood Pressure <130/80
0
10
20
30
40
50
60
70
80
90
100
Dr.A Dr.B
Dr.C
Dr.D Dr.E
Dr.F
Dr.G
Clin
ic C
SMD
C P
rimar
yC
are
Provider
% o
f pro
vide
rs' d
iabe
tic p
atie
nt p
opul
atio
n
Jun-07 Sep-07 Dec-07 Mar-08 Apr-08 May-08 Jun-08
Target = 50%
Feedback to Physicians and Staff: Physician Level
Encounters Per Support Staff FTEPhoenix Pilot Site #1
156149 149
174
190
143
172 171
152 151 153 149
205214
-
50
100
150
200
250
FY 2005 FY 2006 FY 2007 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008
July August September October November December January February March April May
Fiscal Period
Enco
unte
rs
Encounter Per Direct Support Staff FTE Poly. (Encounter Per Direct Support Staff FTE)
Implementation Feb 08
Phoenix Project: Impact on Disease Management
• Integration of population-based disease management into “routine” care
• Decrease in missed opportunities for lab work and increased % of patients up-to-date (A1C, LDL, etc)
• Future appointments and labs scheduled before patient leaves the clinic, whenever possible
• Improved patient engagement in self-management– RN Coach: Alert fires within EHR for patients meeting criteria for referral – Patients receive After Visit Summary that clearly communicates what
occurred during their visit, including instructions and “next steps”• Prepared proactive care team
– Lab results available at time of appt increase effectiveness of pt visit• Intentional and focused efforts to enhance disease management has
led to health plan collaboration and improved reimbursement structure
Ongoing Challenges• Change Management
– “There is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things.” Machiavelli, The Prince, 1513
• Physician Engagement
• Clinical Inertia
• Unexplained Variance• Reluctance in system to hold individuals accountable for
implementation and results, i.e. “culture of consequences”
• “No Net New“– Ensuring that efficiencies gained allow for value added activities
without increase in resources• Value must be defined by external customer (patients and
families) rather than internal (staff, physician, payers)
Lessons Learned
• Implementing lean thinking in a traditional health care culture is not “for the faint of heart” (IHI)
• Communication is essential• Do not underestimate the response to change in status quo• The vocal, unhappy minority cannot steer the ship• Senior leadership support is invaluable• Involve patients in planning process• Not a “quick fix”
– Improvement to metrics will take time– Will require sustained commitment
• Clear definition of roles and responsibilities will help project move forward
• “You get what you expect and you deserve what you tolerate”
Questions ?
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Averbeck, Beth and Beth Waterman. (2007, May 17). Embedding Reliability in Ambulatory Care: The Care Model Process. Presented at the 2007 ICSI/IHI Colloquium at Minneapolis, Minnesota.
Bodenheimer T., et al.: Improving primary care for patients with chronic illness. JAMA 288:1775-1779,October 9, 2002.
Bodenheimer T., et al.: Improving primary care for patients with chronic illness. Part Two: The chronic care model. JAMA 288:1909-1914,October 16, 2002.
Dorr D., et al.: Disease management: Implementing a multi-disease chronic care model in primary care using people and technology. Disease Management 9:1-15, February 1, 2006.
Going Lean in Health Care. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2005. (Available on www.IHI.org)
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