Optimizing PACE: OPOE II Learning Collaborative PACE_… · Learning Objectives At the conclusion of this session you should be able to: 1. Understand the basic principles of Lean

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


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”



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


• 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


• Project Team

• Current State

• Data Analysis




• Lessons Learned

• Q & A


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%


47


• Scheduling/Capacity Visibility

• Primary Nursing

• Rooming Process Communication

• Management of Clinic Walk-ins


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


• Project Team

• Current State

• Data Analysis




• Lessons Learned

• Q & A


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%


• 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


• Future State – Process Map


Timeline Visio


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


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%


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


• Project Team

• Current State

• Data Analysis




• Lessons Learned

• Q & A

QUESTIONS???

IDT Meeting and Communication Project

Emily Martin MPH, Director of Quality and Performance Improvement

[email protected]

Hollis Graham RN, BSN Director of Strategy, Innovation and Transformation

[email protected]

Neighborhood PACE, East Boston, MA


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



Voice of Customer


• 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


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 [email protected]

▪ Selena Pittman [email protected]

▪ Kimberly Henderson [email protected]

Neighborhood PACE :

▪ Emily Martin [email protected]

▪ Hollis Graham [email protected]

▪ Kelly Marcella [email protected]

PACE CNY

▪ Donna White [email protected]

▪ Nicole Esposito [email protected]

▪ Paul Heins [email protected]

Center for Elders’ Independence

▪ Radiant Scoggins [email protected]

▪ Michelle Taylor Lagunas [email protected]

▪ Maria Christina Pingol [email protected]

On Lok Lifeways:

▪ Nicole Torres [email protected]

▪ Sharron Kahoalii [email protected]

▪ Jonathan Chau [email protected]

mailto:[email protected]















Documents

Optimizing PACE: OPOE II Learning Collaborative PACE_… · Learning Objectives At the conclusion of this session you should be able to: 1. Understand the basic principles of Lean