Business Process Redesign in Health Care IT

1. Business Process Redesign in Health Care IT Types of BPR Project Management Implications Examples from the Field Lee Farabaugh, Susan John, Larry Katzovitz, Eric Lott, AshwiniPatki, Jessica Pearce, Josh Snow Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

2. Group 4: Project Agenda • Overview of Business Process Redesign models used in healthcare. • Applicability of principles of Business Process redesign related to overall Project Management methodologies. • Effectiveness of such models as part of a Healthcare IT initiative. • Examples where organizations have used such a model as part of a Healthcare IT initiative. • Class exercise and questions.

3. Project Management Methodologies (Traditional) • Waterfall • Spiral • Build and Fix

4. Traditional Methodology Model • Identify Deficiencies • Define Specific Proposals for Improvement • Proposed System is Designed • New System is Developed • System is Implemented • System is Continuously Evaluated and Maintained

5. Traditional Methodologies Characteristics • Looked to improve existing systems or implement new systems • Task oriented • Processed based • Step-by-step approach

6. Business Process Redesign Characteristics • “Clean Slate” • Outcomes oriented • Priority based • Cyclical approach

7. Business Process Redesign Model • Envision New Processes • Initiate Change • Diagnosis Process • Process Redesign • Reconstruction • Process Monitoring

8. Agile Principles • Projects built around self-organized teams • Rapid adaptation to changing circumstances • Continuous attention to technical design • Working product is the measure of progress

9. Health Care Challenges that encourage use of BPR • Medical errors and high costs of healthcare • Underinsured or uninsured population • Increasing number of heterogeneous and older population, • Globalization/ medical outsourcing, • Maintaining quality for given cost and cost minimization for given quality • Shortage of clinical and nursing staff

10. Expectations from BPR models • Increase in efficiency • Reduce medical and medication errors • Health care cost reduction • Better access and quality in healthcare • Procedure optimization • Time effectiveness • Customer and health care provider satisfaction

11. Highlighted solutions • Automating and monitoring processes in healthcare • Redesigning or improving clinical processes where necessary and possible • Identifying patient expectations and improving patient care processes for better customer services.

12. BPR – What & Why? • Business Process Redesign is a set of activities undertaken to make sustained improvements in the … • SPEED (lead time) • QUALITY • COST OF PROCESS HELPS AN ORGANIZATION STAY COMPETITIVE IN THE MARKETPLACE

13. BPR – How? HIGH LEVEL ASSESSMENT RESULTS IN NEW PRODUCT REDESIGN (FOR EFFICIENCY & ALIGNMENT OF MUTUAL GOALS) • BUSINESSS MISSION • GOALS • CUSTOMER NEEDS • STRUCTURED ORDERING OF WORKSTEPS • MEASURED • IMPROVED • (OR) ELIMINATED

14. BPR - Methods • LEAN • SIX SIGMA • TOTAL QUALITY MANAGEMENT (TQM) • KAIZEN • PLAN, DO, STUDY ACT (PDSA) • CLINICAL MICROSYSTEM MODEL • TALENT PROFILING

15. LEAN – What? RETHINKING & REDESIGN OF BUSINESS PROCESS EFFICIENCY IMPROVEMENTS PROCESS COST REDUCTION REVENUE INCREASE SHORTENED LEAD TIMES REDUCED PROCESS WASTES IMPROVED CUSTOMER SATISFACTION

16. LEAN – How? HIGH LEVEL ASSESSMENT WHO ? PRODUCT DELIVERED ?

17. LEAN – How? Improving Processesby eliminating… STEPS THAT HAVE NO VALUE PROCESS WASTE WAITING TIME

18. LEAN – How? (Six Concepts) • Value • Value Stream • Flow • Pull • Perfection • Replication

19. LEAN – What helps? STRONG MANAGEMENT SUPPORT & SPONSORSHIP COMMUNICATION OF SHARED GOALS LEAN IMPLEMENTATIONS

20. LEAN - Conclusion • Can be applied to any business process or service industry. • Can be used to dramatically reduce lead times • HR recruitment • New product development • Customer development TO GAIN COMPETITIVE ADVANTAGE OVER OTHER COMPANIES

21. Six Sigma (Six sigma was invented by Motorola in the 1980s) • Analytical approach to indentify the inefficiencies and inadequacies in the process and provide a step by step solution based on analysis of real time data. • Process must have < 3.4 defects per million occurrences (Carrigan, 2006) • Statistical calculation that suggests customer needs /satisfaction to meet 99.99997% or 6-Sigma level. (Caldwell 2006) • Focuses on customer satisfaction, process improvement and cost reduction. (Breyfogle, 2003) • Uses structured methodology and powerful statistical tools that provide a scientific approach to process improvement and patient safety. (http://www.medscape.com)

22. Six Sigma Sub methodologies • DMAIC: Define, Measure, Analyze, Improve, and Control; (improve existing processes ) • DMADV: Define, Measure, Analyze, Design, Verify; (develop new processes or products at Six Sigma quality levels) (http://www.isixsigma.com/sixsigma/six_sigma.asp) • Implementing 6sigma: “Black Belt” = organize of Six Sigma project “Green belt” = implement and monitor the project.

23. Applications of BPRBPR Obstacles Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

24. What is TQM? • Total Quality Management (TQM) is a philosophy that says uniform commitment to quality in all areas of an organization promotes an organizational culture that meets consumers' perceptions of quality. • TQM philosophy focuses on teamwork, increasing customer satisfaction, and lowering costs. The concept of TQM rests largely on five principles: 1. Produce quality work the first time. 2. Focus on the customer. 3. Have a strategic approach to improvement. 4. Improve continuously. 5. Encourage mutual respect and teamwork. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

25. TQM Process/Benefits • Process begins by listening to customers' wants and needs and then delivering goods and services that fulfill these desires. • An effective TQM program has numerous benefits: • Financial benefits (lower costs, higher returns on sales and investment, and the ability to charge higher rather than competitive prices) • Improved access to global markets • Higher customer retention levels • Less time required to develop new innovations • Reputation as a quality firm • Http://www.cliffsnotes.com/WileyCDA/CliffsReviewTopic/Total-Quality-Management-TQM-.topicArticleId-8944,articleId-8931.html#ixzz0WJep9lSX Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

26. What is Kaizen? • Philosophy/practices focusing on continuous improvement in manufacturing activities, business activities, & life in general. • Refers to activities that continually improve all functions of a business, • Manufacturing to management • CEO to assembly line workers • Kaizen aims to eliminate waste. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

27. Kaizen Cycle • The cycle of kaizen activity can be defined as: • Standardize an operation • Measure the standardized operation • Gauge measurements against requirements • Innovate to meet requirements and increase productivity • Standardize the new, improved operations • Continue cycle ad infinitum Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

28. Kaizen • http://www.valuebasedmanagement.net/methods_kaizen.html Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

29. Other BPR Methods PDSA – Plan, Do, Study, Act Clinical Microsystem Model Talent Profiling Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

30. PDSA – Plan, Do, Study, Act Three Questions • What are we trying to accomplish? • How will we know that a change is an improvement? • What changes can we make that will result in improvement? Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

31. The PDSA Cycle Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

32. PDSA – UW Rheumatology Office Visit Data Collection • Cycle 1 – Standardized Database & Dictation Template • Cycle 2 – Disease Activity Scoring • Cycle 3 – CPT Visit Coding Level • Cycle 4 – Full Implementation Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

33. PDSA – UW Rheumatology Office Visit Data Collection Improvements • More Complete Data • 40% Time Savings • More Effective Patient/Physician Visit • Improved Therapeutic Decision Making • Research Study Revenue Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

34. Clinical Microsystem Method • Smallest Replicable Unit • Building Blocks to Larger System • 5 P’s - Purpose, Patients, Processes, Professionals, and Patterns   • Improvements – Transformation of Workforce and Culture • Hospital Quality = Quality of Microsystem 1 + Quality of Microsystem 2 + Quality of Microsystem 3 and Microsystem (n) Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

35. Talent Profiling • Worker rather than Process • Right Person – Right Job • Important Characteristics to be Successful Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

36. Business Process Reengineering and Health Care IT • IT often plays a support role in BPR in health care • “What has to happen when you design the new process, you find how information technology is going to be used to support that new process, and if you don’t have that technological capability, you’re going to have to go and get it.” (George W. Whetsell) Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

37. Denver Health (Lean) • Pure IT project: patient scheduling application development • Project timeline reduced 50%, outside consulting cost reduced 36%. • IS had previously sat “on the sidelines” in lean initiatives, but sought to use lean to make the department more efficient • Challenge was to fit lean concepts to a longer term IT project. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

38. Denver Health (Lean) • Rapid Improvement Event (RIE) model was tweaked to fit this specific project • Embedded into project cycle, redefining how project was managed • Custom templates created • Special attention given to lean tools, activity flow, and frequency of RIE events • Involvement of end users • “Red phone” mentality Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

39. BayCare Health & Blue Cross • Optimize Electronics Claims Processing • Understand Sub-processes in claims processing • Blackbelts held team meetings • Six page swim lane process map • Results • Reduced processing time • Fewer denied claims • $500,000 annual savings Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

40. VA’s VistA QUERI system (TQM) • Quality Improvement initiative within the VA, where data from the organization’s nationwide interoperable VistA EMR system is integral to the total process of improving patient outcomes. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

41. Hynes, D. M., Perrin, R. A., Rappaport, S., Stevens, J. M., & Demakis, J. G. Informatics Resources to Support Health Care: Quality Improvement in the Veterans Health Administration. Journal of the American Medical Informatics Association. 2(5), 344-350. Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

42. Virginia Mason (Lean) • IT served as a support role to improve areas identified as cost-centers • Provided feedback to individual clinicians on cost performance • Implementation of CPOE to reduce unnecessary prescriptions and reduce ER visits due to low refill allowances • Implementation of decision support to alert clinicians when tests fall into the “not useful” category Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

43. BPR Recap • Methods • How different from traditional • Variety of methods • Application Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

44. Q&A • Questions? Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

45. Class Exercise Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

46. Business Process Redesign: Jeopardy Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

47. Jeopardy Questions (Modified Version) Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

48. Jeopardy Answers Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

49. Bibliography • Alexandrou, Marios (2009). Methodologies. Retrieved from http://www.mariosalaxandrou.com • Beck, K., Beedle M., Bennekum, A., et al. (2001), The Agile Manifesto. Retrieved from http://agilemanifesto.org • Caldwell, C., Lean-Six Sigma tools for rapid cycle cost reduction, Healthcare Financial Management. Oct 2006, 60 (10) • CliffsNotes.com. Total Quality Management (TQM). 24 Nov 2009. Retrieved from http://www.cliffsnotes.com/WileyCDA/CliffsReviewTopic/topicArticleId-8944,articleId-8931.html • Corn, J. B.,Six Sigma in Health Care, Radiologic Technology. September/October 2009; 81(1): 92-95 • Bergman, R. (1994). Reengineering Healthcare. Hospitals & Health Networks. 5 February, 1994, 28-36. • Breyfogle, F. W., Implementing Six Sigma: Smarter Solutions Using Statistical Methods, 2nd ed. 2003, Wiley, New York, NY. • Carrigan M. D., Kujawa D. Six Sigma in health care management and strategy. Health Care Management. 2006;25(2):133-141 • Caldwell, C., Lean-Six Sigma tools for rapid cycle cost reduction, Healthcare Financial Management. Oct 2006, 60 (10) • Davenport, D. and Short, J. The New Industrial Engineering: Information Technology and Business Process Redesign. Retrieved from http://www.archive.org/details/newindustrialeng00dave • Guha, S., Kettinger, W., & Teng, T. (1993) “Business Process Reengineering: Building a Comprehensive Methodology”, Information Systems Management, Summer 1993, Vol 10 (3), 13-22

50. Harrington, T. J., Newman, E. D. (2007). Redesigning the care of rheumatic diseases at the practice and system levels. Clinical and Experimental Rheumatology, 25, S55-S63. • Improvement Methods. Institute of Healthcare Management. Retrieved from http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/ • Lanham, B., Maxson-Cooper, P. Is Six Sigma the Answer for Nursing to Reduce Medical Errors...: Implementing Six Sigma in Health Care. MedScape Today. Retrieved fromhttp://www.medscape.com/viewarticle/449692_6 • Mahalik, P. Learning to Think Lean: Six Steps with Review Points. Retrieved from http://www.isixsigma.com/library/content/c060821a.asp • McQueen, H. E. (1993). The healthcare CIO’s role in business process redesign. Computers in Healthcare. February, 1993, 24-28. • Mohr, J, Batalden, P., Barach, P. (2004). Intergrating patient safety into the clinical microsystem. Qual Saf Health Care, 13,34-38. • Plan-Do-Study-Act (PDSA) Cycle (2008). AHRQ Healthcare Innovations Exchange. Retrieved from http://www.innovations.ahrq.gov/content.aspx?id=2398 • Schweikhart S. A., Dembe A. E. J Investigative Medicine. 2009 Sep 2 • Shaffer, Vi. (2008). Case Study: Denver Health Leverages ‘Lean’ for a Breakthrough in Enterprise Patient Scheduling Implementation. Gartner Industry Research. 17 December, 2008. • Six Sigma. Retrieved from http://www.pqa.net/ProdServices/sixsigma/sixsigma.html • Six Sigma - What is Six Sigma? Retrieved from http://www.isixsigma.com/sixsigma/six_sigma.asp • ValueBasedManagement.com. Kaizen Philosophy and Kaizen Method. Retrieved from: http://www.valuebasedmanagement.net/methods_kaizen.html