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Optimizing PACE:
OPOE II Learning Collaborative
OPOE II Learning Collaborative PACE Organizations
Learning Objectives
At the conclusion of this session you should be able to:
1. Understand the basic principles of Lean and Six Sigma.
2. Describe how Lean and Six Sigma methodology can be effectively implemented in PACE.
3. Understand performance improvement results achieved by PACE Organizations participating the OPOE II Learning Collaborative.
What is OPOE?
The Optimizing PACE Operations and Efficiencies
(OPOE) program was launched in 2015. Since its
inception, NPA has coordinated two OPOE learning
collaboratives, consisting of a total of 10 PACE
organizations. The program applies Lean and Six
Sigma methods to begin developing cultures of
continuous improvement in PACE.
OPOE I Learning Collaborative: PACE Organizations
● Midland Care Connection (Kansas)
● ArchCare (New York)
● Bienvivir Senior Health Services (Texas)
● New Courtland LIFE (Pennsylvania)
● PACE of Rhode Island
● McGregor PACE (Ohio)
● On Lok Lifeways (California)
● PACE CNY (New York)
● Centers for Elders’ Independence (California)
● Neighborhood PACE (Massachusetts)
OPOE II Learning Collaborative: PACE Organizations
Lean & Six Sigma: Better together
Change Management
Organizations don’t change;
people within organizations change
OPOE 2 Process Improvement Projects
The following projects will be discussed today:
▪ Pre-Day at the Center (DAC) Intake Process
o McGregor PACE
▪ Gee Clinic Operations Optimization Project
o On Lok Lifeways
▪ Clinic Scheduling
o PACE CNY
▪ Improving the Dining Experience
o Centers for Elders’ Independence (CEI)
▪ IDT Meetings and Communications Project
o Neighborhood PACE
Pre-Day at the Center (DAC) Intake Process
Selena Pittman, Director of Social Services
Margie Hirsch, Director of Dietary Services
Kim Henderson, CFO
McGregor PACE
Overview
• Background/Problem Statement
• Project Team
• Current State
• Lean Six Sigma Process and Tools
• Improvements Implemented
• Data Analysis
• Success Metrics & Benefits
• Lessons Learned
• Q & A
Background/Problem Statement
• McGregor PACE started as a small plan (~150 participants) were departments were run inefficiently
• Quickly experienced significant growth where old processes were not sufficient to meet demand
• Experienced turnover of Intake Director and staff several times
• Enrollments decreased over time
Project Team
• Green Belts
• Intake Coordinators
• Intake Nurse
• Eligibility Manager
• Social Work Manager
• Subject Matter Experts: Medical Records, Primary Care Physicians, Occupational Therapy
Current State
SIPOC DIAGRAMStreamlining Pre-DAC Intake Process
Suppliers Input Process Output Customers
Community
resources
phone call to
PACE Receive Referral
DAC
schedul
ed
Potential
EnrolleeIntake
coordinator
Five pager
completed
Intake meets with
potential enrollee
RN/OT/SW
Initial
assessment
In-home assessment
occursEnrollee/Family
/Guardian
Enrollee's
financial data
Eligibility initiates MCD
processMedical
Records Staff
Medical
Record
PCPs review medical
documentationPotential
enrollee 2399 Form DAC scheduled
Lean Six Sigma Process/Tools
Improvements Implemented
• Reduce and streamline the intake application process and documents
• Moved medical record intake process to Medical Records Department
• Implement staff education programs on program services & eligibility
• Increase in community presentations to reach a wider referral base
Data Analysis
0%
5%
10%
15%
20%
25%
30%
May 2017 July 2018
Conversion Rates
Success Metrics & Benefits
• With the new Pre-DAC Intake Process in place, McGregor PACE has greatly improved their conversion rates. We improved referral to enrollment ratio from 13% to 26.5%.
• We increased enrollment on average by 2.69 participants per month. This translated into an increase in net operating margin of $172,000 over a 12 month period.
Lessons Learned
• What things would you do again next time?o Diverse selection of the team who have both indirect and direct responsibilities in
the project
• What things would you do differently next time?o Closer monitoring prior to handing off to Process Owner
o GEMBA Walk (prior/post RIE)
o Data collection prior to selection of projecto More feedback from staff both pre/post RIE
• Any additional advice for a PACE program considering adopting Lean Six Sigma principles?o Focus first on projects that have a large impact on your organization’s bottom line
o Make sure you set aside designated time to work on projects
o Seek out ways make quick wins
o Promote Promote Promote the principles of Lean Six Sigma!
QUESTIONS???
Gee Clinic Operations Optimization Project (GCOOP)
Sharron Kahoalii, Director of EHR Products
Jonathan Chau, Director of Regulatory Affairs & Compliance
Nicole Torres, Director of Program Management
On Lok Lifeways
All About On Lok
Original Vision: • Help the low-income seniors in Chinatown/North Beach area of
San Francisco stay in their own homes• National prototype for the Program of All-inclusive Care for the
Elderly (PACE) model of care
Today:• On Lok Lifeways, our PACE program, serves over 1,500 seniors in
three San Francisco Bay Area counties • On Lok’s 30th Senior Center services over 6,000 seniors annually with
traditional senior center services• Owns and operates three senior housing buildings• Provides consultation through PACEpartners consulting • Owns Care at Home Medicare home health agency
Background/Problem Statement
The current throughput process in the Gee Clinic for scheduled participant visits (Visit Type = RN only visit) is inefficient, non-standardized and results in participant experiencing long wait times and multiple moves.
o Total wait time consists of the combination of Clinic Reception, Clinic Hallways, and/or Clinic Rooms (Exam, Treatment or Lab) wait times when there were no treatment/services being received.
o Total moves consist of any physical movement of the participant from one care space to the next within the clinic area.
Project Team Structure
PROGRAM MANAGEMENT
Champions: David Nolan, COO
Eileen Kunz, CGAC
Finance Representative: Tiffany Luong, FP&A
Green Belts: Jonathan Chau, Nicole Torres, Sharron Kahoalii
Process Owners: Teresa Pham, MD, Melanie Munsayac, RN, Evangeline Mijares, PM, Harmony Young,
PM, Christine Peneyra, RN, Christian Coffman, RN
Project Coordinator: Fei Teng, MSG
Core Team: Gee Clinic Staff: RN, LVN, MA, CNA, PCP
Workflow Tiger Team
Interpreter Role Tiger Team
Physical Space Tiger Team
Technology Tiger Team
Scheduling Tiger Team
Data Analysis
✓ Gathered “As-Is” data by conducting 30 GEMBA Walks during
participant clinic visits.
✓ Found that 73% (22 out of 30 cases) of the total wait times are less than
20 minutes and 87% (26 out of 30 cases) resulted in 3 “Moves” or less.
✓ Goal was to control the participant total wait time to no more than 20
minutes, and reduce the number of participant moves between spaces
in a clinic visit to 3 or less for 100% of the time.
Current State“Walking the GEMBA”
RIE Week
Rapid Improvement Event (KAIZEN): 5 day event involving key stakeholders
focused on solving a narrowly scoped process improvement opportunity.
Activities:
Kickoff Message from Leadership Champions, Process Owners & Core Team
Introduction to LSS for Team & Agenda Core Team
Current State Analysis Core Team
Future State Analysis Core Team
Prioritization of Improvement Opportunities Core Team
Tollgate #1 Champions, Process Owners, & Core Team
Just Do Its Core Team; Extended Team (if needed)
Additional approvals (if needed) Core Team; Extended Team (if needed)
Communication Plan Core Team
High Level Action Plan/Preliminary Control Plan Core Team
Tollgate #2 Champions, Process Owners, & Core Team
Current StateSIPOC
Summarizing Clinic Appointment Visits Inputs & Outputs:
Root Cause Analysis“6M’s - Fishbone”
Root Cause Analysis“6M’s - Fishbone”
RIE Week in Action
“Physical Space”
“5s”: Organizing your workspace for effectiveness and efficiencies
5s – “Just Do It”
5s – “Just Do It”
5s – “Just Do It”
34
5s Activities
35
SORT: Red Tag Activity
STRAIGHTEN: Straighten Activity
SHINE: Shine Activity
STANDARDIZED: 2 checklists (inventory list, supplies list)
SUSTAIN: 5s checklist
5s Improvements
Improvements Implemented
• Clinic Workflow JDI’s
o Solutions were identified and implemented to immediately improve workflow, supply management, team communication, and physical space.
• Physical Space JDI’s
o Solutions identified and implemented to reorganize clinic space in order to maximize usage of the current space and label and standardize clinic supplies and equipment inventory and placement.
• Clinic Scheduling
o Solutions identified and implemented to schedule participant clinic visits using “care units” with enhancements to current clinic scheduler. Developed Clinic Dashboard to load balance the physical care spaces and care units.
• Optimization of Interpreter Services
o Solutions were identified and implemented to maximize role of the interpreter to support basic staffing and participant needs while in the clinic.
Lessons Learned
• Dedicated and committed resources
o Staffing - Need GBs who have bandwidth to lead GB projects
o Time - Competing priorities with our projects and ongoing process improvement initiatives
o $$ - Allocate sufficient budget to carry out GB projects
• Change management process
o Understanding change management theories/models
o Understand that “it’s not just for factories”
o Need regular communication plan
o Why Lean Six Sigma?
• Integration of LSS with our Project Management Office
Work In Progress
• 5s Implementation
• Hiring new Clinic Coordinator
• Implement Participant Tracking Software
QUESTIONS???
Clinic Scheduling
Nicole Esposito, RN - Director of Site Operations – PACE CNY
Donna White, MS, RN – Director of Quality - PACE CNY
Overview
• Background/Problem Statement
• Project Team
• Current State
• Data Analysis
• Lean Six Sigma Process and Tools
• Improvements Implemented
• Success Metrics & Benefits
• Lessons Learned
• Q & A
Background/Problem Statement
The internal clinic scheduling process of nursing and provider visits was resulting in up to 50% cancelled and missed visits.
This created inefficient work flows, dissatisfaction amongst participants and discontented staff.
Project Team
Current State
45
Data Analysis
27.4% Cancelled visits but the baseline cancellations were up to as much as 50%
Lean Six Sigma Process/Tools
47
Improvements Implemented
• Scheduling/Capacity Visibility
• Primary Nursing
• Rooming Process Communication
• Management of Clinic Walk-ins
Success Metrics & Benefits
Total VisitsTotal AttendedTotal Cancelled
NURSING VISITSPROVIDER VISITS
Lessons Learned
• What things would you do again next time?oUse a variety of process improvement tools
oComplete the RIE process in consecutive days
• What things would you do differently next time?oChoose a less complex problem for your first RIE
• Any additional advice for a PACE program considering adopting Lean Six Sigma principles?
QUESTIONS???
Improving the Dining Experience
Radiant Scoggins, LCSW, Center Director
Centers for Elders’ Independence (CEI)
Overview
• Background/Problem Statement
• Project Team
• Current State
• Data Analysis
• Lean Six Sigma Process and Tools
• Improvements Implemented
• Success Metrics & Benefits
• Lessons Learned
• Q & A
Background/Problem Statement
In 2016, CEI participants reported a less than optimaldining experience during lunchtime, while attending the daycenter. Statistics revealed lower than targeted goals of 90%across three meal metrics*. For example, the BerkeleyPACE Center meal metric results from the 2016 ISATscores identified a decrease from 60% in 2015 to 37% intaste. Although overall lunch satisfaction increased from72% (2015) to 84% (2016), there was room forimprovement to meet the goal of 90% across all metrics.
*Meal Metrics: Taste, Presentation, Variety
Project Team
• Champions:
o Linda Trowbridge, CEO
o Aaron McPherson, Vice President of Operations
o Justin Lola, IS Director
• Team Members:
o Christina Pingol, Nurse Practitioner –Green Belt
o Michelle Taylor-Lagunas, Center Director –Green Belt
o Radiant Scoggins, Center Director – Green Belt
o Sunita Ram, Center Geriatric Aide Lead
o Carol Habercoss, Nutrition Services Manager
o Jan Speer, Food Vender and Registered Dietician
o Deb Schwark, Associate Center Director and Registered Dietician
o Emily Hoshida, Center Director
Project Team
Current State
Root Cause Analysis - Variety
Current State
Root Cause Analysis - Appearance
Current State
Root Cause Analysis - Taste
Current State
Data Analysis
Process Metrics and Improvement Goals
Metric:
Meal Presentation
Taste
Variety
Overall Dining Experience
* Baseline scores taken from the Berkeley Pace
Site only
Baseline:
63%
37%
68%
84%
Goal:
90%
90%
90%
90%
Lean Six Sigma Process/Tools
• Rapid Improvement Events
o July 18 - July 19, 2017
o September 6 - September 7,2018
• Voice of the Customer – Participant survey
o Total interviewed:90 participants
Lean Six Sigma Process/Tools
• Future State – Process Map
Lean Six Sigma Process/Tools
Timeline Visio
Improvements Implemented
Ambiance Taste/flavor Variety
• Tablecloths
• Staff aprons
• Table menu
• New dishware
• LED candles
• Soft music
(classical or jazz)
• Infused Olive oil on
cooked vegetables
• Salt added during
cook phase
• Al Dente
vegetables
• New Sandwich
Alternative
• Increased salad
options
• Soup and Salad
entree
Success Metrics & Benefits
The annual ISAT interviews took place in October 2017. The results of the ISATscores showed improvement in participant satisfaction with meal service althoughimplementation took place one month prior to the interviews. The Scores at BerkeleyImproved from 37% in 2016 to 67% in 2017 for taste. In 2017, Participants wereasked to rate their satisfaction with the Customer Service during meal time at CEI asa new ISAT question and Berkeley scored 94%.
Quality Indicator 2016 BRK 2017 BRK
Lunches look good 63% 69%
Lunches taste good 37% 67%
Gets a variety of foods
here68% 78%
Summary score 56% 70%
Overall lunch rating 84% 86%
Success Metrics & Benefits
On-going staff training with emphasis on customer service and providing a restaurant-like
experience is key to the sustainability of this project. “The meals we get now at CEI are
excellent. The key to a good meal is environment and the tablecloth, dishes, condiments
and table menu bring class to the meal”- C.W - CEI participant.
Lessons Learned
• Communication and Preparation is
essential
• Sustainability Planning
• Staff Buy – In
• Incorporate Lean Six Sigma into
Company Culture
Overview
• Background/Problem Statement
• Project Team
• Current State
• Data Analysis
• Lean Six Sigma Process and Tools
• Improvements Implemented
• Success Metrics & Benefits
• Lessons Learned
• Q & A
QUESTIONS???
IDT Meeting and Communication Project
Emily Martin MPH, Director of Quality and Performance Improvement
MartinE@ebnhc.org
Hollis Graham RN, BSN Director of Strategy, Innovation and Transformation
GrahamH@ebnhc.org
Neighborhood PACE, East Boston, MA
Background/Problem Statement
We hold daily meetings from 8:30-9:30am at our three main centers to discuss participant care coordination, staff coverage, service requests, care plan reviews and other care-related topics. In addition, each site holds a weekly Care Plan Review meeting on Monday afternoons.
By restructuring IDT and other meetings, Neighborhood PACE sees an opportunity to increase clinical availability and meet regulatory requirements more efficiently, specifically care plan and service request review.
The problems with the meetings are: • Meetings occurs during prime clinic hours when IDT members could
be seeing patients or completing and reviewing chart notes. • As some staff cover multiple sites, we do not always have a full 11
member team present for topics that require all members for decision-making. This was a compliance finding in our most recent audit.
Project Team
Current State
We spend over 500 labor hours per week just in IDT meetings, morning meetings and Skilled Nursing Facility care coordination meetings.
In our current meeting structure, we are sometimes non compliant with the CMS Regulations= Audit Findings.
Data Analysis
Care Plan Compliance* Q1 Jan-March Q2 April-June
All IDT members present at discussion
15% 75%
All assessments completed prior to Care Plan Review
40% 70%
Service Request Compliance*
Q1 Jan-March Q2 April-June
All IDT members present at discussion
30% 90%
All service request assessments completed prior to review
90% 80%
*Based on a random sample
Lean Six Sigma Process/Tools
Lean Six Sigma Process/Tools
Voice of Customer
Improvements Implemented
• Restructured the schedule and agenda for the IDT meetings and Morning Meetings
• Eliminated phone meetings with Skilled Nursing Facilities to coordinate care by implementing e-transfer of knowledge are care coordination
• Utilization of intranet info sharing and team organization
Success Metrics & Benefits
Labor Hours
• 15,600 staff labor hours reallocated annually
• Clinical time starts 1 hour earlier
Compliance
• Care Plans and Service Requests reviewed with full IDT
• More coordinated care
Quality
• Expectations for staff conduct at meetings
• Care coordination documented
Lessons Learned
Change Management is a difficult skill.
Creating a culture that embraces change is difficult. It is important to have ALL the key business owners share in the same vision.
Full assessment of the issue is critical.
Finding the root cause can take time and deep discussion.
Staffing issues in the workgroup can hinder progress.
Time commitment involved for staff; picking the right staff to be on the workgroup.
Communication
How often, with whom and with what structure.
QUESTIONS???
OPOE II Learning Collaborative Green Belts
McGregor PACE:
▪ Margaret Hirsch Margaret.Hirsch@mcgregorctr.org
▪ Selena Pittman selena.pittman@mcgregorctr.org
▪ Kimberly Henderson kimberly.henderson@mcgregoramasa.org
Neighborhood PACE :
▪ Emily Martin martine@ebnhc.org
▪ Hollis Graham grahamh@ebnhc.org
▪ Kelly Marcella marcellk@ebnhc.org
PACE CNY
▪ Donna White dwhite@lorettosystem.org
▪ Nicole Esposito nesposit@lorettosystem.org
▪ Paul Heins pheins@lorettosystem.org
Center for Elders’ Independence
▪ Radiant Scoggins rwedeman@cei.elders.org
▪ Michelle Taylor Lagunas MTLagunas@cei.elders.org
▪ Maria Christina Pingol MPingol@cei.elders.org
On Lok Lifeways:
▪ Nicole Torres nicole@onlok.org
▪ Sharron Kahoalii skahoalii@onlok.org
▪ Jonathan Chau jchau@onlok.org
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