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Transformation of a Service Operations System through Lean Process Improvement
- 1. TransformationofaServiceOperations SystemthroughLeanProcess ImprovementandLearning Collaboration Behavioral Operations Management Conference, INSEAD Business School, Fontainebleau, France, June, 2011 Linda LaGanga, Ph.D., LPC Director of Quality Systems & Operational Excellence Mental Health Center of Denver Denver, CO, USA Linda.Laganga@mhcd.org Additional information available at: https://secure.smhcd.org/OutcomesPubs.aspx Behavioral Operations -2011, © Linda LaGanga, 2011 1
- 2. What’sthisActionResearchabout? • HealthcareServiceOperationsSystems – Configure – Deliver – Measure – Improve • TheContinuumofHealthcare • LeanTransformationandLearning Collaboration inInpatienttoOutpatientSettings • TimelinessinAccesstoCare • TheLeanParadox Behavioral Operations -2011, © Linda LaGanga, 2011
- 3. ResearchinImprovingOutpatient HealthcareOperations Capacity Expansion Process Improvement Appointment LeanProcess CQI Scheduling Improvement Decision utility model, Action research, Interviews and To overbook or not Empirical case study pilot surveys LaGanga & Lawrence LaGanga Kovach, (2007, DSJ) (2011, JOM) Fredendall, PresentationObjective: LaGanga) • PositionActionResearchwithseveral (2011, DSI) methodologies&philosophies • ConsiderareasofresearchinterestinBehavioral OpsManagement Behavioral Operations -2011, © Linda LaGanga, 2011 3
- 4. The2‐DimensionalContinuumofHealthcare Physical Health Inpatient Services / Emergency Department Outpatient Services Mental Health / Behavioral Health Behavioral Operations -2011, © Linda LaGanga, 2011 4
- 5. FirstHealthcareDeliveryOrganization WinsShingoPrizein2011 • DenverHealthwins forLeanSystemsImprovement • DenverHealthexecutivesestimatetheprogram saved$88millioninoperationalexpenses • Helpedsafeguardall5,500DenverHealthjobs. • Eveninapooreconomy,didn’thavetocutcarefor thecity'suninsuredandunderserved. • Auge,DenverPost,3/23/11,“DenverHealthWins InternationalAwardforEfficiency.” Behavioral Operations -2011, © Linda LaGanga, 2011 5
- 6. LeanTransitiontoOutpatientSettings • HospitalstoOutpatient – Clinicsrunbyhospitals – Collaboratingoutpatientsystems • OutpatientCommunityMentalHealthCenter – ExpandAccess – ReduceProcesstimes – Streamlinedocumentation – Coordinatecare – Improvetreatmentplanning – Enhancefunding Behavioral Operations -2011, © Linda LaGanga, 2011 6
- 7. LanguageandValues • Applyingmanufacturingprincipletohealth andhumanservices • “Ourproductispeople” • Measureandreportwhatpeopleunderstand andvalue • Productivity • “ConsumerServiceHours” Behavioral Operations -2011, © Linda LaGanga, 2011 7
- 8. Value:EnhanceFunding andTreatmentOutcomes • HealthcareFunding • ProcessMeasures – Counting – Compliance • ServiceEffectiveness – OutcomesMeasures – Throughputtoservemorepeople – Communityimpact – Costeffectiveness Behavioral Operations -2011, © Linda LaGanga, 2011 8
- 9. StretchYourDollar $ TheMentalHealthCenterofDenveradmitted 400newadultswithseriousmentalillnessintohigh intensityservicesthefirstyearofimplementationof itsRecoveryNeedsLevelinstrumentwith no additionalresources. $ Basedonacostof$12,500perconsumer = Totalpubliccostsavingannuallyis $5Million. Reaching Recovery, © 2011 Behavioral Operations -2011, © Linda LaGanga, 2011
- 10. CourttoCommunityTreatmentOutcomes • After18months: • 2/3HaveNotBeenRe‐Arrested • 80%ReductioninJailTime • $104,790SavingstoTaxpayers Changein#ofJailDays:AllClients 2000 N=1873 1600 #JailDays 1200 80%Reduction 800 N=376 400 0 Pre Post AdmissionPeriod Behavioral Operations -2011, © Linda LaGanga, 2011 10
- 11. Reaching Recovery, © 2011 Behavioral Operations -2011, © Linda LaGanga, 2011
- 12. ExampleofaLeanImprovementProject andtheContinuumofCare • CoordinatedandIntegratedHealthcareServices • MotivationforLeanImprovement: ReduceEmergencyRoomandinpatientuseinBehavioral HealthSetting • Goals: – 25%reductionofMedicaid‐fundedinpatientcostsforBehavioral Healthcareforcalendaryear2010 – Increasedcollaborationbetweeninpatientandoutpatient providers. – Increasedfinancialresourcesforoutpatientservices. – Availabilityofcorrectlevelofservicewhenneeded Behavioral Operations -2011, © Linda LaGanga, 2011 12
- 13. MeasuresandSources • Claimsdata – Hospitaladmissionrates – Averagelengthofstay – EmergencyRoomutilization – Hospitalrecidivism – Follow‐upratesafterdischarge • Externalbenchmarkingagainstothermanagedcare organizations • Outpatientadmissions – Callcenterdata – ElectronicMedicalRecord – ServiceRequests – Admissions – Timetoappointments – Showrates Behavioral Operations -2011, © Linda LaGanga, 2011 13
- 14. KeyLeanProject • TimelinessInAccesstoCare • RapidImprovementCapacityExpansion(RICE) – ConcentratedonAppointmentAllocation/AssignmentProcess – Shiftingandincreasingappointmentavailability – IncreasingShowRate – Matchinginteractionstoconsumerneeds • LaGanga,2011.LeanServiceOperations: ReflectionsandNewDirectionsforCapacityExpansion inOutpatientClinics.JournalofOperationsManagement29(5). • Researchstartedasappointmentschedulingmodelsforno‐shows andoverbooking;evolvedtoleanfocus. Behavioral Operations -2011, © Linda LaGanga, 2011 14
- 15. ConfigurationofAppointmentAllocationSystem Supplier Customer Access Center Clinical Intake Teams Consumers Seeking Access Check appointment Receive call inventory for from consumer availability Consumer not admitted. Exits but Release appointments to may call days of the scheduling week again. Monday No slots available or no appropriate match for consumer Inventory ofTuesday Appointments Wednesday Consumer given an Intake Consumer Match consumer appointment. exits, waits to appointment slot and for Thursday remove appointment Intake from inventory appointment. of available appointments Friday Behavioral Operations -2011, © Linda LaGanga, 2011 15
- 16. IntakeProcess:BeforeLeanImprovement Consumers Providers Orientation Orientation Orientation Orientation Idle Intake Clinician due to consumer no-show Delay (Days) Consumer leaves and doesn’t return Individual Intake Individual Assessment Intake Individual Assessment Intake Assessment Idle Intake Clinician due to consumer no-show Delay (Days) Consumer leaves and doesn’t return Individual Psychiatric Individual Evaluation Psychiatric Evaluation Idle Psychiatrists due to consumer no- shows Exit: Completed Intakes Behavioral Operations -2011, © Linda LaGanga, 2011 16
- 17. IntakeProcess:AfterLeanImprovement Consumers Providers Orientation Overbooked consumer who shows up Individual Intake Individual Assessment Intake Individual Assessment Intake Individual Assessment Intake Assessment Clinician called into service for overbooked consumer who showed up Behavioral Operations -2011, © Linda LaGanga, 2011 17
- 18. IntakeProcess BeforeandAfter Consumers Providers Consumers Providers Orientatio n Orientati Orientatio n Orientatio on n Orientatio n Idle Intake Clinician due to Overbooked consumer no- consumer who show shows up Individu Delay Consumer (Days) alIndividu leaves and doesn’t return Intake alIndividu al Individua Assess Intake Individual mentl Assess Intake Intake Individual Intake Clinician called into ment Assess Assessme Intake Individual Assess service for ment ntAssessme Intake ment overbooked ntAssessme consumer who nt showed up Idle Intake Clinician due to consumer no- show Delay Consumer (Days) leaves and doesn’t return Individual Psychiatri Individual c Psychiatri Evaluation c Evaluation Idle Psychiatrists due to consumer no-shows Exit: Completed Intakes Behavioral Operations -2011, © Linda LaGanga, 2011 18
- 19. Appointmentsscheduledandno‐showrates beforeandafterleanimprovement Before Appointments Scheduled After 500 400 300 200 100 0 Mon Tue Wed Thu Fri Before No-Show Rates After 20% 15% 10% 5% 0% Mon Tue Wed Thu Fri Behavioral Operations -2011, © Linda LaGanga, 2011
- 20. LeanProcessImprovement:OneYearAfter RapidImprovementCapacityExpansion RICEResults • Analysisofthe1,726intakeappointmentsfortheoneyear beforeandthefullyearaftertheleanproject • 27%increaseinservicecapacity – from703to890keptappointments)tointakenewconsumers • 12%reductionintheno‐showrate – from14%to2%no‐show • Capacityincreaseof187additionalpeople whowere abletoaccessneededservices,withoutincreasingstafforotherexpensesforthese services • 93fewerno‐shows forintakeappointmentsduringthefirstfullyearof RICE improvedoperations. • Annualcostsavings(expenseavoidance): $90,000‐ $100,000 forstaffingandspace Behavioral Operations -2011, © Linda LaGanga, 2011 20
- 21. Improvement in accessibility and timely access to services based on service value in lean outpatient health care (based on Womack and Jones, 2005). Before Time Steplikelytorecur? Consumer’s steps and time for admission to services, before lean process improvement. 1.CallAccessCenterforadmissiontoservices. 10minutes Yes 2.Noslotavailable.Waittocallagain. 3days‐1week Yes 3.CallAccessCenterforadmissiontoservices. 10minutes Yes 4.Possibleslotavailable.Providemoreassessmentinformation. 15minutes Yes 5.Noappropriateslotavailable.Waittocallagain. 3days‐1week Yes 6.CallAccessCenterforadmissiontoservices.Providemoreassessmentinformation. 30minutes. No Appropriateslotobtained.Appointmentsmadefororientationandintakeassessment. 7.Waitfororientation. 1– 7days. No 8.Orientationforpaperwork,explanationofpoliciesandprocedures. 50minutes No 9.WaitforIntakeAssessmentsession. 1– 7days. No 10.IntakeAssessmentsessionwithindividualclinician. 60‐90minutes. No Totaltime(minimumpossible) 2days+140 minutes Totaltime(maximumifconsumerisadmittedon4th call) 5weeks245 minutes Actualclinicalservicetime(value‐creatingtime) 60‐90minutes Totalstepswithrecurrentsteps Behavioral Operations -2011, © Linda LaGanga, 2011 14
- 22. Improvement in accessibility and timely access to services after Lean Improvement Consumer’sstepsandtimeforadmissiontoservices,after Time Step likely to recur? leanprocessimprovement. 1. Call Access Center for admission to services. 10 minutes Yes 2. No slot available. Wait to call again. 1 – 3 days Yes 3. Call Access Center for admission to services. 10 minutes 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. 30 minutes. No Appropriate slot obtained. Appointment made for orientation and sequential intake assessment. 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 Behavioral Operations -2011, © Linda LaGanga, 2011 Total steps with recurrent steps POMS-2011, Linda 12 ©22
- 23. Comparing process steps: Before and After • Before: • Totalstepswithrecurrentsteps(worstcasewith 3instancesofsteps4and5)=3x3+5=14 • After • Totalstepswithrecurrentsteps(worstcase with2instancesofsteps4and5)= 2x3+6=12 • Eliminates2steps Behavioral Operations -2011, © Linda LaGanga, 2011
- 24. Comparing process time and lag time: • Before: • Totaltime(minimumpossible)=(30+50+60minutes)+2days =2days2hoursand20minutes • Totaltime(maximumifconsumerisadmittedon4th call) • =5weeks4hoursand5minutes • After: • Totaltime(minimumpossible)=Sameasabove • Totaltime(maximumifconsumerisadmittedon3rd call) • =1week3hoursand10minutes • Processandlagtimereductionofworstcase: • >4weeks Behavioral Operations -2011, © Linda LaGanga, 2011
- 25. ProcessImprovement • Accomplishedbyinvolvingcliniciansandconsumers • Reconfigurationfortimelyandconsumer‐friendly access • Measured – Increasedintakes – Decreasedno‐showrates – Decreaseddelaystoaccess • Multi‐dimensionalimpacts(projections) – Reducedinpatientexpenses – Physical/Behavioraldimensionsofhealthcare • Transition • Transformation Behavioral Operations -2011, © Linda LaGanga, 2011
- 26. Whatisthe LeanParadox? • Just‐in‐time? – NO • NewBottlenecks? – YES • RapidImprovement? – NOT! • Solutions – Clearoutprojectclutter – Prioritize – Realignproject scheduling • Sustainabilityand humanbehavior Behavioral Operations -2011, © Linda LaGanga, 2011 26
- 27. TransformationofaServiceOperations SystemthroughLeanProcess ImprovementandLearning Questions? Collaboration Comments? Behavioral Operations Management Conference, INSEAD Business School, Fontainebleau, France, June, 2011 Linda LaGanga, Ph.D. Director of Quality Systems & Operational Excellence Mental Health Center of Denver Denver, CO, USA Linda.Laganga@mhcd.org Additional information available at: https://secure.smhcd.org/OutcomesPubs.aspx Behavioral Operations -2011, © Linda LaGanga, 2011 27