A Journey to Value-Based CarePutting Lean Six Sigma and Automation in Place

BY JEFFREY GALLES, D.O., AND JERRY GREEN, PH.D.

To move from volume-based reimbursement, Utica

Park Clinic examines its processes for managing

patient populations, applies Lean principles

to improve them, and then explores IT-driven

automation to drive improvement.

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NOVEMBER/DECEMBER 2014 AMGA.ORG ❘ GROUP PRACTICE JOURNAL 13

Although many primary care providers (PCPs) have adopted population health management (PHM) goals as they transition from volume- to value-based reimbursement, the infrastructure required to manage populations at the clinic level is still emerging.

In many cases, practices are eager to deploy new technologies designed to help them become more effi -cient. Yet the reality is, if the practice’s current pro-cesses are not sound, then automating those processes will only make the practice more effi cient at being inef-fi cient. For this reason, we fi nd it best to start the PHM journey by examining current processes for managing patient populations and then applying Lean and Six Sigma principles to improve them. Once better pro-cesses are in place, IT-driven automation can then drive signifi cant improvement around PHM, helping PCPs to maximize effi ciency and achieve the Triple Aim of improving the experience of care and population health while reducing its cost.

Here we will provide an overview of how to apply Lean principles to improve practice effi ciency. Along the way, we will drill down to describe how applying these principles—in concert with the use of PHM tech-nology from its partner, Phytel—contributed to PHM success at Utica Park Clinic in Tulsa, Oklahoma, part of the Ardent Health System.

Re-engineer Work� owsFor those unfamiliar with it, Lean is a continuous

quality improvement method that motivates front-line workers to reduce cycle time by eliminating waste. Introduced decades ago in relation to a Toyota produc-tion model and often associated with Six Sigma, which focuses on removing the causes of defects and mini-mizing variability in business processes, it is now an accepted approach in many industries.

A small but growing number of healthcare organi-zations have fully adopted Lean principles to improve quality and reduce waste by re-engineering workfl ows. Many providers are beginning to move down the Lean path. Utica Park Clinic is among the early adopters. And while automation is not required to apply Lean in health care, automation tools and other types of health IT are powerful adjuncts to transforming health care based on the Lean approach—especially around many routine care management tasks.

Several Lean principles apply to health care:

■ Value is defi ned from the patient’s perspective.

■ Workfl ow is analyzed and broken down into a series of steps so that any failure in the process can be easily identifi ed.

■ Waste is removed from the workfl ow so the process fl ows without interruption.

■ Problems are addressed immediately through rapid experimentation with proposed solutions.

■ Ideas that succeed are spread throughout the organization.

■ Most important, people at all levels are expected to contribute suggestions for improvement and participate in testing “countermeasures” to solve problems.1

This last concept can be particularly diffi cult for PCPs. Health care is organized along hierarchical lines that are diffi cult to break, with physicians at the top of the pyramid. Lean thinking fl attens hierarchies to achieve quality improvement.

Management must free employees to criticize exist-ing processes and suggest ways to improve them. For their part, physicians must be willing to delegate tasks to care teams and allow them to fi nd ways to improve workfl ow, add value to the process, and make a PHM initiative succeed.

Create Affordable Care TeamsOne way to break down barriers to drive process

improvement involves creating care teams that include a variety of clinical and nonclinical staff. By sharing responsibility for care among team members, high-per-forming practices increase their capacity and productiv-ity while changing how they view each other.

Launching a PHM-coordinated care team model can be culturally and fi nancially challenging. It of-ten requires additional staff and technology that few small practices can afford.2 Strategic leaders, however, recognize that investing in team-based care today is im-perative for success tomorrow as value-based payment becomes dominant.

Some health plans offer to offset the cost of putting care teams in place by paying care coordination fees and/or incentiviziny practices that have been recognized as Patient-Centered Medical Homes (PCMHs), which incorporate such teams into their structure.3 Value-based reimbursement may also offset the cost of care teams through shared savings and risk contracts with a quality component.4

PCPs that deliver that type of value while increas-ing their own effi ciency should do well in the emerging world of value-based reimbursement—well enough to justify the extra overhead care teams add to practices. The knowledge and coordination these teams bring is also critical to driving change from the bottom up—the Lean approach.

A Journey to Value-Based CarePutting Lean Six Sigma and Automation in Place

BY JEFFREY GALLES, D.O., AND JERRY GREEN, PH.D.

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14 GROUP PRACTICE JOURNAL x AMGA.ORG NOVEMBER/DECEMBER 2014

Transform Problem AreasThere are four problem areas common to most

practices that are in need of transformation if they are to facilitate population health:

■■ The previsit process encounter is not optimized.

■■ PCPs often do not know their patients were admitted to a hospital.

■■ Patients at risk for acute events are not identified proactively.

■■ Care teams are not working at the top of their license.

Lean and Six Sigma principles help practices de-velop solutions for all these concerns.

Optimize Pre-Visit Encounters Fixing the process. In many practices, previsit

planning is a manual process that grew organically over time. Because there was no actual planning, it is often riddled with waste and inefficiency.

Lean’s traditional Define, Measure, Analyze, Im-prove, Control (DMAIC) approach to process manage-ment has a huge impact here. It starts with defining both the current state and the desired state (i.e., where you want to go). In PHM, especially in a value-based model, that usually means finding a reliable way to identify care gaps for the most at-risk patients and pro-viding them with a high level of care and attention such as contacting them to remind them to make an office visit appointment or have a particular procedure (lab, mammogram, colonoscopy, etc.) performed.

“At-risk” doesn’t just mean the sickest patients. They normally only represent the top 2 or 3 percent of the population. An at-risk group includes the 67 percent currently considered healthy but on course for a catastrophic event in the next year.

Mapping. Next comes cross-functional value stream mapping. This is where the care team approach and flattening the hierarchy become critical. In the value stream map, the care team visualizes the workflow end-to-end horizontally to identify areas in which interruptions to continuous flow occur. Everyone on the team must feel comfortable critiquing the current state and making suggestions for process improvement to occur. Pareto charts are extremely valuable at this stage to identify the 20 percent of value stream issues that contribute 80 percent of the inefficiencies. With this information in hand, the team can determine how to adjust and simplify the work, reduce waste, and improve efficiency as well as patient outcomes and satisfaction.

One outcome of a Lean approach is that many high-performing practices use previsit planning and pretesting to avoid inefficient visits that don’t meet patient needs. A care coordinator might contact an out-of-control diabetic patient who has not visited the provider for some time and ask that person to make an appointment for an HbA1c test prior to the visit so the physician can discuss the results at the next visit.

Automating. Although it is not required, automa-tion can have a significant impact in optimizing the previsit process. For example, by implementing Phytel’s PHM technology, Utica Park Clinic was able to run a report that identified care gaps, including patients overdue for a PCP visit. Care managers used the solu-tion’s automated outreach to contact these patients, make them aware of the gaps, and urge them to make an appointment. Importantly, the technology examined the entire population, not just those who were already in front of clinicians.

By closing these gaps, Utica Park Clinic not only improved patient health significantly, it generated more than $840,000 in additional billable revenue in one year. And that was only for a pilot program involving 60 of its more than 200 providers.

Know When Patients Are HospitalizedFixing the process. Here, Six Sigma DMAIC cre-

ates a process to alert PCPs about hospitalizations. It starts by collecting critical-to-customer quality (CTQ) requirements and uses a Failure Mode and Effects Analysis (FMEA) to identify process design. Quality Functional Deployment identifies and prioritizes mea-sures to focus on.

Mapping. A “To Be” map identifies the perfect pro-cess to care for items identified in CTQs and FMEA.

Automating. For Utica Park, this approach led to embedding four full-time RN care coordinators in its affiliated hospital to work with the group’s patients to assist with the transition of care using PHM technol-ogy. Utica then follows patients with specific Diagnosis Related Groups (DRGs) for 30 days after discharge, lowering the hospital’s risk of readmission. Follow-ing this 30-day window, patients are transferred to an embedded outpatient care coordinator during a “warm hand-off.” PCPs are better informed, and reducing readmissions significantly pays for the PHM program.

Proactively Identify At-Risk Patients Fixing the process. This issue gets to the core value

of PHM. As noted above, at-risk patients are not only those who are sickest today but others who fall below this “water line.” Developing an effective process is

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critical to identifying the entire at-risk population, leveraging data for acute events, and applying hypothe-sis-testing tools to identify relationships between input and outcome variables. A prediction model should be used when feasible.

While core data may reside in electronic health records (EHRs), these tools were not designed for Lean process improvement. Manually searching through EHR charts is a time-consuming, labor-intensive task that is likely to miss important information. With PHM technology, however, care managers stratify an entire patient population (such as diabetics) into high, medi-um, and low risk to instantly determine which patients are at highest risk for complications and/or hospitaliza-tion and attend to them proactively.

Automating. After initiating its automated PHM program, Utica Park Clinic effectively improved patient care through proactive outreach. Utica Park initiated a total of 291,426 patient communications. From this effort, the group successfully reminded patients of 140,000 appointments, informed almost 65,000 of a care gap, and spurred 6,800 to interact with Utica Park providers. In reviewing adherence rates, despite previous trends, it became apparent that the high-risk patients were most responsive to the outreach program. Financially, this effort yielded a 14:1 return on investment (ROI), further allowing the investments in care managers and automated PHM to pay for themselves.

Work at Top of LicensesFixing the process. In a Lean world, the care team

approach requires that practices think about how best to use each team member to provide better care with less waste. A cardinal principle is to enable care team members to work at their top level of training, experi-ence, and ability. For example, physicians should not perform clerical work that does not require their level of knowledge. Nurses should be empowered to do as much as possible within the limits of their licensure.

Automating. The goal is to assign the right patients to the right staff members or to automation only. With risk stratification, the care team decides which approach works best for each individual. A healthy patient may just need automated reminders to maintain wellness and obtain recommended preventive services. Patients at risk of developing a chronic condi-tion might receive automated interventions as well as health coaching from medical assistants. Nurse case managers have responsibility for managing high-risk patients with multiple conditions.

Enabling each care team member to work at the top of their license eliminates waste while ensuring each patient receives the highest level of care. This is another outcome of Utica Park’s approach to Lean. Early suc-cesses are driving culture and process changes elsewhere in the system.

Efficient, Productive, ExtraordinaryThe transformation of healthcare delivery requires

high-performance care teams. By starting with a Lean approach to continuous process improvement and then applying automated tools that leverage PHM, care teams become efficient and productive while helping practices deliver extraordinary value to patients and payers. The Lean approach is key to succeeding in the world of value-based reimbursement.

References1. S.J. Spear. 2005. Fixing Healthcare from the Inside, Today.

Harvard Business Review, 83(9): 78-91. 2. R.J. Baron and E. Desnouee. 2010. The struggle to support

patients’ effort to change their unhealthy behavior. Health Affairs, 29: 953–955.

3. Anthem Blue Cross and Blue Shield of Colorado. March 12, 2014. Press release. More than one-third of Colorado’s primary care providers working under new payment and care coordination arrangement with Anthem. Accessed June 6, 2014 at www.businesswire.com/news/home/20140312006098/en/One-Third-Colorado’s-Primary-Care-Providers-Working-Payment#.Uz8d5BbiQwi.

4. K. Terry. 2010. Physician Payment Reform: What It Could Mean to Doctors—Part 1: Accountable Care organizations. Medscape, August 10, 2010. Accessed June 6, 2014 at www.medscape.com/view article/726537.

Jeffery Galles, D.O., is actively involved in qual-ity improvement as CMO and chairman of the Quality Improvement Council at Utica Park Clinic in Tulsa, Oklahoma. Utica Park Clinic is a division of Hillcrest Healthcare System LLC. Jerry Green, Ph.D., is vice president, quality, at Phytel, Dallas, Texas, providing physicians with proven technology to deliver timely, coordinated care to their patients.

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