Performance improvement in the mobile age

Sawad Thotathil MDCare Coordinates

MA, USA

Organizations and systems become complex over time

3 types of complexity are endemic in healthcare or human services organizations

1. Structural complexity2. Mission creep3. Processes complexityComplexity is costly

Organizational complexity

Restructuring System or process improvement Reducing or limiting service offerings

We believe that Mobile devices and applications provide a new approach to performance improvement

Current approaches to tackling Cost and Quality issues

Mobile devices have become cognitive prosthesis Mobile connect knowledge workers

Businesses can use this additional capability to embed continuous improvement in the system and power innovation

How?1. Data collection at point of service is seamless and can be rapidly

reconfigured to accommodate changes in the environment2. Employee can access data, information and metrics that help make

informed decisions while performing tasks or making judgments3. Employees can be connected to each other to enable knowledge

sharing as well as easier group decision making

How can mobile apps help a human services organization?

Other than cultural impediments, the 2 tactical hurdles to change are1. Difficulty in quickly deploying and field testing

redesigned processes2. Rigid information structures that prevent

iterative improvement Mobile devices can be used to overcome these hurdles as well as promote a new type of culture where performance is transparent and information/knowledge sharing is the norm

Common hurdles to improvement

Platforms such as Salesforce allow managers to 1. Focus on the business problem2. Test out solutions without fear of a costly failure3. Not be constrained by the possibilities predetermined by a software designer4. Embed continuous improvement

How do Apps help business mangers?

During App designa) Teams can map out processes and

workflows that help achieve team objectives and company goals

b) Obtain group consensus on performance metrics that align the company goals with individual work

Implementing ImprovementOwning the change

a) Incremental deployment of features and functions

b) Data streams start working immediately thereby allowing testing of all strategic or operational hypothesis

c) Feedback is used for easy redesign when necessary

Implementing ImprovementFacilitating adoption

Most organizations face the App Gap – No in-house resources to design and maintain apps

External Software developers do not have performance improvement expertise

New platforms like Salesforce allow organizations to deliver apps without an in-house IT department.

Current App scenario

A Group of physicians and Nurse practitioners near Boston, USA providing care to patients at 18 independent skilled nursing facilities

The provider group and the nursing homes are different business entities.

Traditional working styles that are dependent on a) paper based information systemsb) Coordination of work is dependent on meetings or

phone-callsc) Field data collection is very limited thereby hampering

improvement efforts

Case study

Providing high quality physician/nurse practitioner care for patients at multiple skilled nursing facilities

What is required to make this happen? Resources - Availability of providers when care is needed Information systems - Record keeping of each visit

regarding clinical care and for billing purposes Operations competencies – Seamless coordinated care

despite different providers Focus on cost and quality- Discharging appropriately while

length of stay remains optimal

Business strategy

Getting to the App

Is the operational structure adequate? What are the Coordination and

Collaboration needs? How to use the data? How to use knowledge for repeatability?

We try to explain this approach using a case study

Approaching the business problem

Redesigning operations

Scenario: Each facility has their own paper and/or electronic method of clinical record keeping. Problem:1. Provider notes in the patient records from different facilities are not

integrated into one system as the facilities are different businesses. Hence they cannot be used in a single system

2. Provider notes for billing are paper based ,non-uniform and erratically prepared. Errors and missing notes are a frequent occurrence. New patient face-sheets, which are also required for the billing process, have to be collated in parallel. The information has to move from provider to corporate and from there to the billing company

Solution3. Encounter information should come directly from point of care4. Safeguards to prevent errors and missing notes

Requirement 1: Realtime Information systems for

managing operations

Using imaging to move face-sheets direct from point of care to billing company

Point of care electronic submission of encounter information

Reducing missing information with mandated fields

Billing process is tied to the patient follow up process required in Objective 2

Design for Req 1

Scenario– Frequency of visit to a facility based on crude estimation of need. Problem 1. No levelling of daily patient visits by each provider and hence

resources stretched on some days. 2. More random visits than planned visits3. Accurate provider resource planning not possibleSolution4. Force schedule follow up visits. 5. Plan for a certain load of emergent needs every day6. Level out visits across the weekdays7. Level out visits across providers

Requirement 2: Provider availability when it is needed

where it is needed

Planning a Follow-up visit become a mandated process when completing a patient encounter

Automatic creation of follow- up lists Visual tool that helps monitor visit load

across the week Central ability to reschedule evenly across

weekdays and providers

Design for Req 2

A providers schedule seen as a week view

A provider schedule in a week view

CoordinationCommunicating and aligning workflows

Scenario: On the go coordination through texting, phone calls, multiple lists (paper and Online)

Problem: As the number of facilities, patients and providers increased, it became inefficient and unsafe to continue this way

SolutionNew processed that are needed : Who will see the patient and when? (previously addressed)

Knowledge of previous interactions with the patient to be shared other team members

Sharing the care ‘thought process’ with the other providers Delegation of tasks between providers Ensuring closing of tasks Sharing specifics on the social/family environment of the patient

Coordination needs

Each visit information would include a note that makes aware key issues or care ‘pointers’ which are then seen by the follow up provider

Task delegation by provider and date Sharing of notes about the family or other

specifics on the patient record Notes about the patient directed to a specific

providers but available to all providers

How to implement?

Performance MeasurementYou cannot manage what you don’t measure

Scenario: 1. The only ‘truth’ is the billing information available

at long intervals from the billing company2. No information on clinical metrics or for other

business needs Problem Data from the visits is inadequate from clinical

perspective There is no standardized data collection

Data vacuum

Data collection and the dashboard are on the same system

The dashboard, report generation and data collection can be easily redesigned as new business questions or problems arise

Ex: How many patient encounters related to treating cellulitis among other problems? How broad is the problem that new interventions need to be incorporated?

How to implement Improvement?

New Business question Regular operational info

Knowledge managementGetting it right every time, everywhere

Explicit knowledge is knowledge that can be codified into protocols and algorithm Scenario: Knowledge sharing was currently through training sessions in the monthly staff meetings Problem: The protocols are not accessible at the point of service Ex: Best practice in Antibiotic selection

Repeatable service quality through utilization of explicit knowledge

Protocols and algorithms for areas of concern are created or obtained from expert sources

This is made available on the mobile app in a searchable format

Example of a treatment guideline on next slide

How is this achieved?

Where can you apply this approach?1. Mobile teams in healthcare 2. Field work such as social workers, service teams3. Wherever Plan-do-study-act cycles need to be

deployed quickly4. Other environments where there are

opportunities to expedite data collection or decision making using tablets or smartphone use

Performance improvement in the mobile age

sawad72@yahoo.com