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Maximizing ROI During A Maximizing ROI During A Lean TransformationLean Transformation
Typical ROI ParametersTypical ROI Parameters
CostCost StartupStartup RecurringRecurring ConsultantsConsultants PersonnelPersonnel
Expected Returns/BenefitsExpected Returns/Benefits Generally $$$Generally $$$ Could be outcomesCould be outcomes Customer/Employee SatisfactionCustomer/Employee Satisfaction
TimeTime When will we achieve benefits to cover costsWhen will we achieve benefits to cover costs
To Accelerate ROITo Accelerate ROI
↓ ↓ Expense or CostExpense or Cost ↓ ↓ Time Time Modify Goals – Focus on areas with Modify Goals – Focus on areas with
greatest opportunitygreatest opportunity
Lean TransformationLean Transformation
Built in ROIBuilt in ROI ““Only improvement methodology Only improvement methodology
which doesn’t rely on a catastrophic which doesn’t rely on a catastrophic event as a catalyst for change”event as a catalyst for change”
““Ongoing continuous improvement Ongoing continuous improvement through the relentless elimination of through the relentless elimination of waste”waste”
True Lean ROITrue Lean ROI
Dependent on:Dependent on: Staff EngagementStaff Engagement Cultural ChangeCultural Change Success of Kaizen EventsSuccess of Kaizen Events Sustainment of ImprovementSustainment of Improvement
Cultural TransformationCultural Transformation
Cultivating an Cultivating an entire staff of entire staff of “Wasteologists”“Wasteologists”
The value of an The value of an engaged and engaged and aware aware workforce workforce working in the working in the least-waste way least-waste way is is immeasurable immeasurable and invaluableand invaluable
$$$$$$
Staff SatisfactionStaff Satisfaction Patient SatisfactionPatient Satisfaction
Patient SafetyPatient Safety$$$$$$
Staff SatisfactionStaff Satisfaction Patient SatisfactionPatient Satisfaction
Patient SafetyPatient Safety
QUALITYQUALITYImproved processImproved process
Improved flowImproved flowImproved informationImproved information
Transformation TheoryTransformation Theory
Transformation Theory vs. Transformation Theory vs. Healthcare Challenges of TodayHealthcare Challenges of Today
Increased pressure to maximize Increased pressure to maximize returns due to reductions in returns due to reductions in reimbursements and ever changing reimbursements and ever changing healthcare standardshealthcare standards
Demand ROI that are measureable, Demand ROI that are measureable, sound, profitable, and immediatesound, profitable, and immediate
Jacobi Medical Center CampusJacobi Medical Center Campus
FY10 Jacobi NCB
# of Beds 479 243
Discharges 22,100 9200
Outpatient Practices
Visits
386,000 200,000
Emergency Department
Visits
113,400 61,000
Ambulatory Surgery Cases
9,500 2,700
Statistical ProfileStatistical Profile
Jacobi Specialty ProgramsJacobi Specialty Programs
• Emergency
Medicine
• Regional Snakebite
Center
• Level 1 Trauma
Center
• FAA-Approved
Helipad
• Pediatric Trauma
Center
• PICU
• Hyperbaric
Chamber
• NYS-Designated
Regional
• Perinatal Center
• Level III NICU
• Burn Service
• NYS-Designated Stroke
Center
• Medical Oncology
Program
• Breast Service
• Rehabilitation Medicine
• Pediatric Surgery
• Craniomaxillofacial
Surgical Institute
• Cardiac Cath Lab
• Bariatric Surgery
Program
Lean Kaizen EventsLean Kaizen Events
0
100
200
300
400
500
600
700
800
2008 2009 2010
StaffParticipation
# of Kaizen Events # of Staff Participation
149 1478
Examples of Jacobi ImprovementsExamples of Jacobi Improvements
Reduced Dwell Time in ED 3 hours Increased volume of surgeries Increased billing due to a better
registration process Increased Medicaid applications Reduced patient travel, improving
patient safety
OPD Revenue Cycle: OPD Revenue Cycle: Reason For Action Reason For Action
Reasons for Action
• COLLECT ALL EARNED REVENUE
• ONLY COLLECTING 71% of OPD REVENUE
• HIGH VOLUME of DENIALS
• $20 MILLION BUDGET DEFICIT
• HIGH LEVEL of PATIENT ,PROVIDER and EMPLOYEE DISSATISFACTION
Business CaseBusiness Case
••Increase RevenueIncrease Revenue
••Creativity Before CapitalCreativity Before Capital
••Better Understanding of Better Understanding of Work FlowWork Flow
••Better Plan for Better Plan for ImprImpr
••Observe the ProcessObserve the Process
••Identify Front End to Identify Front End to Back End Process for Back End Process for Revenue Revenue
Value StatementValue Statement
•• Respect Respect
•• Complete Complete understanding of understanding of financial responsibilityfinancial responsibility
•• Fast RegistrationFast Registration
•• One stop shoppingOne stop shopping
•• Correct SchedulingCorrect Scheduling
Key RequirementsKey Requirements
•• HIPAAHIPAA
•• EMTALAEMTALA
•• PAR PAR MgdMgd Care Care ContrContr
•• Medicaid / Medicare Medicaid / Medicare Rules/TimeframesRules/Timeframes
•• Corp Mission StmtCorp Mission Stmt
•• Continuum of CareContinuum of Care
•• MD CredentialingMD Credentialing
Measurements Measurements
• % OPD Collections• % of Clean Claims• % Incurred Denials / # of Visits• Revenue• Absenteeism• # OPD Open Visits
• Patient• Staff • Equipment• IT Systems
INPUTSINPUTS
•• General vendors General vendors •• Outpatient PracticesOutpatient Practices•• EquipmentEquipment
SUPPLIERSSUPPLIERS
•• Improvement Improvement Of patient health Of patient health & Visit Satisfaction& Visit Satisfaction•• Collect Earned Collect Earned •• Revenue Revenue
OUTPUTSOUTPUTS
•• Patient Patient
CUSTOMERSCUSTOMERS
••SchedulingScheduling••RegistrationRegistration••Patient EncounterPatient Encounter••Redirect/Return VisitRedirect/Return Visit••ZZ--outout••Close Visit TimelyClose Visit Timely••BillingBilling••FollowFollow--upup••Payment Payment
PROCESSPROCESS
Trigger:Trigger:Patient Requests AppointmentPatient Requests Appointment
Done:Done:Get Appropriate Payment Get Appropriate Payment
OPD Revenue Cycle:OPD Revenue Cycle: Initial State Initial State
Initial State
• INEFFICIENT OUTPATIENT SERVICES
• NOT BILLING for ALL PROVIDER SERVICES
• INEFFECTIVE CODING SYSTEM
• POOR COMMUNICATION PLAN
• POOR REFERRAL SYSTEM
• COLLECTION RATE IS < 72% 160,000# of Visits per Year /
Medicine & Surgery
74%% Payments within 45
Days
62,967 Cash Receipts Reported
(OPD) FY08 (000)
70.16Avg Payment per Visit
50%Collectability all OPD
Services
Base Line Base Line MeasurementsMeasurements
Year 1 - 11 RIEsYear 1 - 11 RIEs
2008 - 2009
Apr 29, 2009 – May 1, 200910. Ophthalmology Out patient Practice Throughput
Mar 23, 2009 – Mar 27, 20097. Managed Care Denials and Appeals
Dec 19, 2008 – Dec 23, 20086. Out Patient Physician Documentation
Nov 21, 2008 – Nov 25, 20085. Rehabilitation and Ophthalmology
Oct 24, 2008 – Oct 28, 20084. Out Patient Managed Care Billing and Denials
Apr 20, 2009 – Apr 24, 20099. Oncology Billing
May 04, 2009 – May 08, 20098. Rules of Engagement
Sept 21, 2009 – Sept 25, 200911. Network Redirection Policy Implementation
Sept 22, 2008 – Sept 26, 20083. Appointment Scheduling
July 28, 2008 – Aug 1, 20082. Standardizing Schedules and Template Process For the Adult Primary Care Practices
June 9, 2008 – June 13, 20081. Ortho
OPD Revenue Cycle
JACOBI RIEs
OPD Revenue Cycle Value Stream:OPD Revenue Cycle Value Stream:Confirmed StateConfirmed State
Confirmed State
• Standardized Process
• Increased Revenue
• Increased Patient Satisfaction
• Improved Employee Morale
97,00062,967 Cash Receipts Reported (OPD)
FY08 (000)
TBD70.16Avg Payment per Visit
85%74%% Payments within 45 Days
160,000160,000# of Visits per Year / Medicine &
Surgery
85%50%Collectability all OPD Services
Target Target Base Line Base Line MeasurementsMeasurements
OPD Revenue Cycle MetricsOPD Revenue Cycle Metrics
JacobiMonthly Breakdown OPD
1000
3000
5000
7000
9000
11000
Month
Cas
h R
ecei
pt
FY08
FY09
FY10
FY11
Linear (FY08)
Linear (FY10)
Linear (FY09)FY08 5392 5128 4603 1339 3509 4021 4384 4197 10087 5599 5487 5764
FY09 4881 5082 4948 4293 4357 5329 4766 5440 6300 10227 5529 6210
FY10 4680 7137 6944 4948 5353 6245 5638 5084 6727 6594 11739 5876
FY11 5796 5436 5416 5768 9010 8428 5951 5830
July August September October November December January February March April May June
OPD Revenue Cycle MetricsOPD Revenue Cycle Metrics
40000
45000
50000
55000
60000
65000
70000
75000
80000
FY08 FY09 FY10 FY11
JMC
20000
22000
24000
26000
28000
30000
32000
34000
36000
FY08 FY09 FY10 FY11
NCB
** FY11 ↑ 8% ↑ 8% Vs FY10 YTDVs FY10 YTD
** FY11 ↑ 5% ↑ 5% Vs FY10 YTDVs FY10 YTD
AED Hospital Wide Flow: AED Hospital Wide Flow: Reason For ActionReason For Action
Reason for Action
• To enhance patient and Staff Satisfaction
• To enhance patient safety
• Poor utilization of professional resources
• Insufficient or inappropriate care
• Suboptimal financial performance
• We are NOT the ED of choice for the Bronx and lower Westchester.
Business CaseBusiness Case
Our beginning efforts at Our beginning efforts at process improvement process improvement will begin with a focus in will begin with a focus in the Emergency Dept. the Emergency Dept. We plan to decrease We plan to decrease dwell time, which will dwell time, which will correlate with an overall correlate with an overall decrease in LOS and decrease in LOS and therefore increase therefore increase capacity in the inpatient capacity in the inpatient units by reducing units by reducing duplication of efforts. duplication of efforts.
Value StatementValue Statement
The patients accessing the The patients accessing the JMC ED value high quality, JMC ED value high quality, timely, and life saving timely, and life saving emergency care in a emergency care in a respectful appropriate respectful appropriate environment, This will environment, This will provide the patient with provide the patient with complete continuity of complete continuity of care covering the full care covering the full spectrum of their spectrum of their healthcare needs. healthcare needs.
Key RequirementsKey Requirements
••SafetySafety
••ConfidentialityConfidentiality
••Regulatory AgenciesRegulatory Agencies
••ProfessionalismProfessionalism
••Educational needsEducational needs
••Appropriate treatment Appropriate treatment and competencies.and competencies.
Measurements Measurements
••Time Door to FloorTime Door to Floor
••Time Door to DoorTime Door to Door
••Walkouts %Walkouts %
••Waiting TimeWaiting Time
••# of Patients# of Patients
••Growth in RevenueGrowth in Revenue
• Patient• Staff • Equipment• IT• Ambulatory• Nursing Homes
INPUTSINPUTS
•• General vendors General vendors •• EMSEMS
SUPPLIERSSUPPLIERS
•• Finance rewardFinance reward•• Wellness of patientWellness of patient•• Safe dischargeSafe discharge•• Pain freePain free•• Physical need metPhysical need met•• Focused on patientFocused on patient•• On timeOn time•• Plan of CarePlan of Care•• Staff Moral Staff Moral •• AppreciationAppreciation•• EducationEducation•• Good work Good work envirenvir..
OUTPUTSOUTPUTS
•• PatientsPatients•• TelemetryTelemetry•• Met Surge UnitsMet Surge Units•• Specialty Units Specialty Units
CUSTOMERSCUSTOMERS
••TriageTriage••Registration Registration ••ED decision to admitED decision to admit••AdmissionAdmission
••EvaluationEvaluation••Treatment Treatment ••Testing / Diagnostic / imaging/LabsTesting / Diagnostic / imaging/Labs••DischargeDischarge••TeachingTeaching••Contacting Admitting ServiceContacting Admitting Service••DocumentationDocumentation••Waiting for consultantsWaiting for consultants••Communication (beds)Communication (beds)••Availability of environmentAvailability of environment
••Support servicesSupport services••EscortEscort••EnvironmentalEnvironmental••SecuritySecurity
••Service Adjudication Level of Care Service Adjudication Level of Care ••SchedulingScheduling
PROCESSPROCESS
Trigger:Trigger:Patient ArrivalPatient Arrival
Done:Done:Patient leaves the ED Patient leaves the ED
AED Hospital Wide Flow: AED Hospital Wide Flow: Initial StateInitial State
Initial State• “Hospital within a hospital” ED is a complex system
• 5 hrs T+R (Excluding wait times) 10 hours dwell time for admissions
• Late discharges / extended LOS
• Low collection rate
• Too many admission denials
• Incompatibility of IT systems
• Safety net providor
0:00:001:00:002:00:003:00:004:00:005:00:006:00:007:00:008:00:009:00:00
10:00:0011:00:0012:00:0013:00:0014:00:0015:00:0016:00:0017:00:0018:00:0019:00:0020:00:0021:00:0022:00:0023:00:0024:00:0025:00:00 JACOBI ED ADMISSION DWELL TIME
Door-to-Admit Decision
Overall Dwell Time ED
Triage to SMAR
Treat & Release Intervals All Patients
0:32 0:29 0:20 0:23 0:21 0:24 0:27 0:23 0:23 0:23 0:20 0:20 0:26
1:47 1:531:25 1:34 1:24 1:27 1:28 1:45
1:21 1:16 1:10 1:25 1:34
2:40 2:40
2:342:38 2:41 2:52 2:43
3:05
2:41 2:432:37
2:382:37
0:00
1:12
2:24
3:36
4:48
6:00
Month
Ho
urs
:Min
ute
s
entry-to-d/c
reg-to-entry
triage-to-reg
AED Hospital Wide Flow: AED Hospital Wide Flow: Target StateTarget State
Target State
• Become ED of choice for Bronx Westchester• 2 Hr 45 min Treat to release • 7 hr door to floor time• Improve HCAPs score to above 90th %tile • Reduce LOS by 1 day• Increase ED collectability to 80%• Meet or exceed industry standards for
admissions denials (3% of admissions)• Maximize utilization of IT systems• 100% ED chart reconciliation
MeasurementsMeasurements TargetTarget Comments Comments
Time Door to Floor 7 hr TPOC target 5 hours
Time Door to Release 2 hr 45 m
Walkouts % < 3 %
Reduction of Waiting Time
40%Pending evaluation of data and way
to measure
Year 1: 11 RIE’sYear 1: 11 RIE’s
2008 - 2009
July 20, 2009 – July 24, 200910. Transfer of Patients Through ICUs
Mar 23, 2009 – Mar 27, 20097. AED-Hospital Wide Flow Admitting
Dec 19, 2008 – Dec 23, 20086. Medicine and Surgery Admission Decisions in ED
Nov 21, 2008 – Nov 25, 20085. AED HIM and Chart Reconciliation Open Visit
Oct 24, 2008 – Oct 28, 20084. AED Logistics and Clinical Support
June 15, 2009 – June 19, 20099. Utilization of Space in Building 8
Apr 13, 2009 – Apr 17, 20098. AED-Hospital Wide Flow Discharge Planning
Sept 21, 2009 – Sept 25, 200911. Treat and Release Patients – Urgent Care
Sept 22, 2008 – Sept 26, 20083. Patient Property “Watch My Stuff”
July 28, 2008 – Aug 1, 20082. Patient Discharge and Chart Processing
June 9, 2008 – June 13, 20081. Registration and Triage in the AED
AED Hospital Wide Flow Value Stream
JACOBI RIEs
AED-Hospital Wide Flow:AED-Hospital Wide Flow:Confirmed StateConfirmed State
Confirmed State
• Performed all RIE identified in the Value Stream• Satisfied patient• Satisfied staff • Sustained improvements • Standardize process • One patient at a time• Zero defects• Coordinate patient demand and bed availability
5.256.25Average Length of Stay
MeasurementsMeasurements Base Line Base Line TargetTarget Comments Comments
Time Door to Floor 11 hr 7m 7 hr TPOC target 5 hours
Time Door to Door 4 hr 32 m 2 hr 45 m
Walkouts % 5.1% < 3 %
Waiting Time TBA 40%Pending evaluation of data and way to
measure
# of Patients (annually) 62,917 TBD Monitor growth in ED patients
CY11 5.5 LOS
Current Value Streams at Jacobi Current Value Streams at Jacobi Medical Center/NBHNMedical Center/NBHN
Nursing - 8 RIEs Radiology – 6 RIEs Peri-Operative Services – 11 RIEs Admitted Patient-Medicine – New Value
Stream Admission/Readmission – 4 RIEs Adult ED Flow – 16 RIEs Behavioral Health Services/Rehabilitation
– 1 RIE
Current Value Streams at NCB Current Value Streams at NCB Medical Center/NBHNMedical Center/NBHN
Nursing - 4 RIEs Revenue in Process – 5 RIEs Women’s Health Services – 10 RIEs Peri-Operative Services – 7 RIEs Medicine – 4 RIEs Behavioral Health Services – 6 RIEs
Maximizing your ROIMaximizing your ROI
Directly related to the success of Directly related to the success of Kaizen EventsKaizen Events
Stacking the Deck for SuccessStacking the Deck for Success
Enterprise GoalsEnterprise Goals
Goals and Targets should be well Goals and Targets should be well defined, inter-related, and support defined, inter-related, and support each othereach other
i.e. if financial performance ↑ but i.e. if financial performance ↑ but patient safety ↓, is this ok?patient safety ↓, is this ok?
LeadershipLeadership
Senior Leadership should be “All In”Senior Leadership should be “All In” Setting goals and participating activelySetting goals and participating actively Encourage and support true Encourage and support true
transparencytransparency Integrate Lean into all hospital-wide Integrate Lean into all hospital-wide
strategic planningstrategic planning
“You don’t know what you don’t know”
Choosing Lean Leader Choosing Lean Leader (Transformation Officer)(Transformation Officer)
Respected in the organizationRespected in the organization Well-KnownWell-Known Have established credentialsHave established credentials
““If you want something done, give it If you want something done, give it to a busy person to do”to a busy person to do”
Integration of Lean MessageIntegration of Lean Message
Consolidate meetings utilizing Lean Consolidate meetings utilizing Lean Metrics and hospital wide dataMetrics and hospital wide data
Agenda at all:Agenda at all: Hospital Wide MeetingsHospital Wide Meetings Service Line MeetingsService Line Meetings Executive MeetingsExecutive Meetings AffiliateAffiliate CAB MeetingCAB Meeting Board MeetingsBoard Meetings
LEAN!
Integration of Lean MessageIntegration of Lean Message
Not the “Flavor Of the Month”Not the “Flavor Of the Month” ““Lean is the Lean is the wayway we work, not in we work, not in
additionaddition to how we work” to how we work”
AAdvertisedvertise
CCommunicateommunicate
EEducateducate
Integration of Lean MessageIntegration of Lean Message
Ongoing Lean CurriculumOngoing Lean Curriculum Part of New Employee OrientationPart of New Employee Orientation Staff Engagement is critical and is the Staff Engagement is critical and is the
key component to maximizing ROIkey component to maximizing ROI As time ↑ and more staff are actively As time ↑ and more staff are actively
practicing Lean, improvement will practicing Lean, improvement will become the way you work and good become the way you work and good won’t be a barrier to greatwon’t be a barrier to great
Aim for Early SuccessAim for Early Success
““Low Hanging Fruit”, “Fruit on the Low Hanging Fruit”, “Fruit on the Floor”Floor”
Sustainment will fertilize the treeSustainment will fertilize the tree Early successes will support spread Early successes will support spread
and enhance the Lean and enhance the Lean transformationtransformation
Metrics for SuccessMetrics for Success
Metrics should be easily defined and Metrics should be easily defined and measurable using existing datameasurable using existing data
““Figures don’t lie, liars figure”Figures don’t lie, liars figure”
Understand the genesis of the Understand the genesis of the data and how it originatesdata and how it originates
Driver MetricsDriver Metrics
Use driver metrics:# of steps saved# of completed
registrations# follow-up phone calls
To ultimately reach targets:Length Of Stay
ReductionRevenue
Length Of Stay
# of Steps# of
handoffs
The best Kaizen Events are….The best Kaizen Events are….
Events that are well choreographed Transformation should not be a random
sequence of events with the results dictated by chance
Plan, Plan, Plan Select proper staff, times, and data Pre-meetings, targets, metrics
“The more I practice the luckier I get”- Gary Player
Scoping EventsScoping Events
Scope the Kaizen Events as tightly as possible
“A mile deep and an inch wide” “Do not boil the ocean” It is the collective changes and
dovetailing of events that will bring the greatest returns
Select subject matter experts at all levels
Lean Words to Live ByLean Words to Live By
Listen! Listen! Listen! Walk Around! Observe!
You don’t know what you don’t know, but your staff does
SustainmentSustainment
Sustainment is the key to a successful transformation and greatly accelerates ROI
Standard work is the critical linchpin for sustainment
Demand It!
Ensuring Lean SuccessEnsuring Lean Success
Assign strong, responsible parties to monitor past event progress/completion plans and follow ups
Have regular scheduled program reviews Target adjustments Identify new areas of focus Priority shifts Future schedules
Lean Lessons to ShareLean Lessons to Share
Creativity Before Capital Flexibility over rigidity There are no “Bad” Events Avoid the “doing more with less”
trap Creates resentment, excuses, makes
bad processes more inefficient, and promotes mediocrity
Don’t Be Shy!!!Don’t Be Shy!!!
Celebrate your success Don’t be afraid to highlight true
progress
Questions? Comments?