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Transformation of a Service Operations System through Lean Process Improvement and Learning Collaboration. Presentation at Behavioral Operations Management Conference. INSEAD Business School, Fontainebleau, France, June, 2011.
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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
Behavioral Operations -2011, © Linda LaGanga, 2011 3
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
Behavioral Operations -2011, © Linda LaGanga, 2011
The 2‐Dimensional Continuum of Healthcare
4
Inpatient Services / Emergency Department Outpatient Services
Mental Health / Behavioral Health
Physical Health
Behavioral Operations -2011, © Linda LaGanga, 2011
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
Behavioral Operations -2011, © Linda LaGanga, 2011
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
6
Behavioral Operations -2011, © Linda LaGanga, 2011 7
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”
Behavioral Operations -2011, © Linda LaGanga, 2011 8
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
Behavioral Operations -2011, © Linda LaGanga, 2011
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
Behavioral Operations -2011, © Linda LaGanga, 2011 10
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
Behavioral Operations -2011, © Linda LaGanga, 2011Reaching Recovery, © 2011
Behavioral Operations -2011, © Linda LaGanga, 2011 12
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
Behavioral Operations -2011, © Linda LaGanga, 2011
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
13
Behavioral Operations -2011, © Linda LaGanga, 2011
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.
14
Behavioral Operations -2011, © Linda LaGanga, 2011 15
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
Behavioral Operations -2011, © Linda LaGanga, 2011 16
Consumers ProvidersOrientation
IndividualIntake Assessment
IndividualIntake Assessment
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
IndividualPsychiatric Evaluation
Idle IntakeClinician due to consumer no-show
OrientationOrientation
Orientation
Exit: Completed Intakes
Intake Process: Before Lean Improvement
Behavioral Operations -2011, © Linda LaGanga, 2011 17
Consumers Providers
IndividualIntake AssessmentIndividual
Intake AssessmentIndividual
Intake Assessment
Orientation
Overbooked consumer who shows up
IndividualIntake Assessment
Clinician called into service for overbooked consumer who showed up
Intake Process: After Lean Improvement
Behavioral Operations -2011, © Linda LaGanga, 2011 18
Consumers Providers
Orientation
IndividualIntake Assessment
IndividualIntake Assessment
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
IndividualPsychiatric Evaluation
Idle IntakeClinician due to consumer no-show
Orientation Orientatio
n Orientation
Exit: Completed Intakes
Consumers Providers
IndividualIntake Assessment
IndividualIntake Assessment
IndividualIntake Assessment
Orientation
Overbooked consumer who shows up
IndividualIntake Assessment
Clinician called into service for overbooked consumer who showed up
Intake ProcessBefore and After
Behavioral Operations -2011, © Linda LaGanga, 2011
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
Behavioral Operations -2011, © Linda LaGanga, 2011 20
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
Behavioral Operations -2011, © Linda LaGanga, 2011
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
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. 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?
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. 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
Behavioral Operations -2011, © Linda LaGanga, 2011
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
Behavioral Operations -2011, © Linda LaGanga, 2011
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
Behavioral Operations -2011, © Linda LaGanga, 2011
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
Behavioral Operations -2011, © Linda LaGanga, 2011
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
26
Behavioral Operations -2011, © Linda LaGanga, 2011 27
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
Questions? Comments?