Optimizing Care Optimizing Care

Mark Murray MD, MPAMark Murray MD, MPA

Gap Between Performance and Gap Between Performance and PossibilityPossibility

For clinical careFor clinical care

For efficiency in careFor efficiency in care

For satisfying care For satisfying care

Gap Exists Gap Exists

Between systems and possibilityBetween systems and possibility

Between sites Between sites

Within sites, between individuals Within sites, between individuals

Narrow the GapNarrow the Gap

Identify the gapIdentify the gap Measure the gapMeasure the gap Identify a goalIdentify a goal Clarify the customer and the value stream Clarify the customer and the value stream Develop a process for improvementDevelop a process for improvement

GoalGoal

Deliver the best care, in the best way, on time, Deliver the best care, in the best way, on time, every timeevery time

Customers and ValueCustomers and Value

The patient (or dyad) is the customerThe patient (or dyad) is the customer

Value: what does the customer valueValue: what does the customer value

How do we deliver that value How do we deliver that value

Delivery of ValueDelivery of Value

At each step we match the demand of service At each step we match the demand of service to the supply of serviceto the supply of service

The work flowsThe work flows The goal is achieved if the work flows The goal is achieved if the work flows

smoothly, if there is perfect balance, all the smoothly, if there is perfect balance, all the time, so that the value is delivered perfectly, time, so that the value is delivered perfectly, on time, every time on time, every time

FailuresFailures

In understanding this dynamicIn understanding this dynamic

In flow - due to imbalances either permanent In flow - due to imbalances either permanent or temporaryor temporary

Role of variation Role of variation

Workflow OptimizationWorkflow Optimization

Perfect balance of demand and Perfect balance of demand and supply/resource all the timesupply/resource all the time

No delays between value steps No delays between value steps No delays at the stepsNo delays at the steps No unnecessary steps or tasksNo unnecessary steps or tasks All steps and tasks are reliableAll steps and tasks are reliable Reduction of delay is the critical operational Reduction of delay is the critical operational

and clinical componentand clinical component

Workflow OptimizationWorkflow Optimization

Harmonic convergence of all critical supply Harmonic convergence of all critical supply componentscomponents

Six dimensions Six dimensions

Balance Is CriticalBalance Is Critical

System levelSystem level

Site levelSite level

““Department” or program levelDepartment” or program level

Individual levelIndividual level

Individual LevelIndividual Level

What does the customer want What does the customer want

How can we best deliver valueHow can we best deliver value Identification of workload balanceIdentification of workload balance Put our clinicians in positions to be successful Put our clinicians in positions to be successful

Individual Level Demand and Individual Level Demand and SupplySupply

Demand comes from the customerDemand comes from the customer Demand for a myriad of services Demand for a myriad of services Direct service and supporting servicesDirect service and supporting services Focus on outpatient office delivery Focus on outpatient office delivery Supply: time is a toolSupply: time is a tool Demand has to = supply Demand has to = supply

Critical Design Elements for the Critical Design Elements for the Perfect SystemPerfect System

No delay- all waits are badNo delay- all waits are bad

Continuity (see your own) Continuity (see your own)

No Wait CultureNo Wait Culture

Every system is perfectly designed to get the Every system is perfectly designed to get the results that it doesresults that it does

Delays are a system property Delays are a system property We can eliminate the delaysWe can eliminate the delays It takes a process for improvementIt takes a process for improvement

ContinuityContinuity

Identification of demandIdentification of demand Identification of population that generates the Identification of population that generates the

demand demand ““Panel”Panel” Formal enrollment process Formal enrollment process Continuity is the likelihood of the demand Continuity is the likelihood of the demand

meeting the supplymeeting the supply Value of that linkage - satisfactions, costs, Value of that linkage - satisfactions, costs,

revenues and clinicalrevenues and clinical

BalanceBalance

Demand has to equal supplyDemand has to equal supply

Measure supplyMeasure supply

Measure demandMeasure demand

Macro demand is panel sizeMacro demand is panel size

Panel SizePanel Size

Has to be the right sizeHas to be the right size Does not have to be the same sizeDoes not have to be the same size How to identifyHow to identify

4 cut method4 cut method Enrollment formal or informal Enrollment formal or informal

Panel limit and formula Panel limit and formula

FormulaFormula

Panel times expectant patient visits per year = Panel times expectant patient visits per year = physician visits per day times days worked per physician visits per day times days worked per yearyear

Value in HealthcareValue in Healthcare

We sell relationshipWe sell relationship

Optimization of relationshipOptimization of relationship

Constraints and limits Constraints and limits

Can or should physicians do all the operational Can or should physicians do all the operational work? The clinical work?work? The clinical work?

HelpHelp

Teams for operational work in order to get the Teams for operational work in order to get the work to the worker just in time work to the worker just in time

The role of the operational team is to put the The role of the operational team is to put the clinician in a position to create the successful clinician in a position to create the successful relationship relationship

Teams for the clinical workTeams for the clinical work

Clinical CareClinical Care

Delivered by individualsDelivered by individuals

Delivered by standardized, supported and co-Delivered by standardized, supported and co-coordinated teams coordinated teams

OptimizationOptimization

Linkage to identified provider of careLinkage to identified provider of care

Accomplished without delayAccomplished without delay

Delivered in a systematic way: standardized, Delivered in a systematic way: standardized, co-coordinated, supported team with clear co-coordinated, supported team with clear accountability and leadership accountability and leadership

Process for ImprovementProcess for Improvement

TeamTeam

AimAim

ChangeChange

Measure Measure

PrinciplesPrinciples

To reduce delays for or between servicesTo reduce delays for or between services

To reduce delays at service To reduce delays at service

To improve clinical care To improve clinical care

SummarySummary

Optimization requires us to follow the Optimization requires us to follow the customer and to understand the dynamiccustomer and to understand the dynamic

The patient is the customer and the dynamic is The patient is the customer and the dynamic is matching demand to supplymatching demand to supply

The most effective, efficient and satisfying The most effective, efficient and satisfying systems will match the demand to the supply systems will match the demand to the supply without delaywithout delay

Matching requires balance Matching requires balance

Summary ContinuedSummary Continued

The balance has to be achieved at all levels, The balance has to be achieved at all levels, down to the individual physicians leveldown to the individual physicians level

Any imbalance creates expanding delay or Any imbalance creates expanding delay or turbulenceturbulence

Continuity is kingContinuity is king Panel is measurement of demand and Panel is measurement of demand and

workloadworkload Continuity is measure of successful action Continuity is measure of successful action

ImplicationsImplications

IF we see this, what are the system IF we see this, what are the system implications implications

Implications: Wait TimeImplications: Wait Time

With the right balance, we can eliminate With the right balance, we can eliminate delaysdelays

Have to deal with variationHave to deal with variation What is the focus: waits or variationWhat is the focus: waits or variation

Implications: Panel Implications: Panel

Workload balance requires balance at all levelsWorkload balance requires balance at all levels ““Panel” is the individual levelPanel” is the individual level Panel has to right sizePanel has to right size Continuous measurement of panel is requiredContinuous measurement of panel is required Accountability is driven to the dyad levelAccountability is driven to the dyad level

Implications: SatisfactionImplications: Satisfaction

With increased continuity satisfaction will riseWith increased continuity satisfaction will rise Offers opportunity for self care Offers opportunity for self care Offers opportunity for leverage both internal Offers opportunity for leverage both internal

and externaland external

Implications: Clinical CareImplications: Clinical Care

With reduced waits and with increased With reduced waits and with increased continuity, clinical care will improve continuity, clinical care will improve

We need to measure We need to measure We need to look for unique opportunities for We need to look for unique opportunities for

leverage presented by short delays and leverage presented by short delays and improved continuity improved continuity

The best clinical care is not achieved by visits The best clinical care is not achieved by visits alone alone

Implications: CostImplications: Cost

With improved continuity and less waits there With improved continuity and less waits there is less system cost: rework, redundancy, triage, is less system cost: rework, redundancy, triage, no shows no shows

Less visits per patient per yearLess visits per patient per year Less workload at the continuity visitLess workload at the continuity visit Reduced visit length, more visits possibleReduced visit length, more visits possible

Implications: VisitsImplications: Visits

Less visits per patient per yearLess visits per patient per year Opportunity for increased replacement visits Opportunity for increased replacement visits

by growthby growth External growthExternal growth Internal growth Internal growth

Implications: Net Revenue Implications: Net Revenue

Gross revenue minus costGross revenue minus cost Cost goes downCost goes down Visits go down but can be replaced Visits go down but can be replaced Visit length with continuity is shorterVisit length with continuity is shorter Visits or visit length with “team” is reduced or Visits or visit length with “team” is reduced or

shorter shorter