Implementation and Impacts of Lean Redesigns in Primary Care

Implementation and Impacts of Lean Redesigns in Primary Care

Implementation and Impacts of Lean Redesigns in Primary Care October 28, 2016 Presenter: Dorothy Hung, Ph.D., Associate Scientist Palo Alto Medical Foundation Research Institute Moderator: Michael Harrison, Ph.D., Senior Social Scientist Center for Delivery, Organization, and Markets, AHRQ Discussant: Arlene Bierman, M.D., M.S., Director Center for Evidence and Practice Improvement, AHRQ Project Team: Carrie Gray, Ph.D., Su-Ying Liang, Ph.D., Meghan Martinez, M.P.H., Hal Luft, Ph.D., Deanne Wiley, C.R.A., Julie A. Schmittdiel, Ph.D. This study was supported by a task order under AHRQs ACTION II contract. Its findings do not reflect the view of AHRQ or any federal agency. Palo Alto Medical Foundation (PAMF) Multispecialty, not-for-profit ambulatory care delivery system Serves nearly 1 million patients Spans 4 counties in San Francisco

Bay Area 1500 physicians, 6700 non-MD staff Majority fee-for-service: - 70% commercial FFS - 12% commercial HMO - 13% Medicare/Medicaid - 5% Self-pay or Other What is Lean? Set of principles, practices, and problem-solving tools that aim to improve efficiency and quality Founded on 2 basic principles - Respect for people - Continuous improvement (PDSA) Key practices and tools: CrossCrossFunctional Functional Management

Management Daily Management Implementation of Lean in Primary Care Sequence of spread across primary care clinics 1 pilot clinic in 1 region Lean-based improvements 3 beta test clinics in 3 regions Value Stream Mapping 5S of Workspace Call

Management Workflow (Flow) Redesign 13 remaining clinics across all 4 regions Flow Redesigns: Co-location of MD/MA dyads Daily huddles Agenda setting In-basket management Conceptual Framework Identify contextual factors impacting frontline acceptance and reported adoption of Lean redesigns in primary care Examples of CFIR-PR domains

Consolidated Framework for Implementation Research modified for studying Process Redesign (CFIR-PR) Source: Rojas Smith L, Ashok M, Dy SM, Wines RC, Teixeira-Poit S. Contextual Frameworks for Research on the Implementation of Complex System Interventions. Methods Research Report. (Prepared by the RTI InternationalUniversity of North Carolina at Chapel Hill Evidence-based Practice Center under Contract No. 290-2007-10056-I). AHRQ Publication No. 14-EHC014-EF. Rockville, MD: Agency for Healthcare Research and Quality; March 2014. 1. Outer Setting: external pressures and policy changes 2. Intervention Characteristics: colocation, standardizations of tasks 3. Individual/Team Characteristics: physician and staff roles/scope of work 4. Inner Setting: networks and communications, culture 5. Process of Implementation: implementation style, execution, employee engagement 6. Measures of Implementation: acceptance, adoption, appropriateness, fidelity, adaptability, cost

7. Outcomes: efficiency, clinical quality, physician productivity, workforce and patient satisfaction Qualitative Data Sources In-depth interviews (N=113) - Physicians - Clinic leaders Focus Groups (N=11 groups, 3-6 members each) - Medical Assistants Observations (N=20) - Events - Workflows In-depth Interviews by Professional Role Contacted Interviewed Frontline Physicians Family Practitioners 72

26 Internists 58 19 Pediatricians 47 24 Physician Leaders 21 21 Operations Leaders

24 23 Total interviews 222 113 Organizational Leaders Qualitative Analytic Methods Coding of fieldnotes and transcripts - Codes emerged from data - Refined codes to align with CFIR-PR domains Focused analysis on CFIR-PR Measures of Implementation: Acceptance, reported Adoption of Lean redesigns - Categorized interviews according to implementation - Compared differences between context, acceptance, adoption Atlas.ti software used to manage data and facilitate analysis

Measures of Implementation Study results focused on two implementation measures: Acceptance Degree to which those impacted by the Lean change effort viewed the changes as acceptable in principle Adoption The reported adoption, attempt to adopt, or conversely, abandonment of Lean redesigns in practice Outer Setting External pressures and policy changes influenced the acceptance of Lean as a solution for primary care. Burning platform, Hamster health care Just grinding out patients as a primary care docit feels like emptying the ocean with a teaspoon. The psyche of being a primary care doctor these days has got to get better Its

hard to be on a treadmill Physician The burning platform was really our affordability targets and how are we going to weather [the year] when we come upon it. Clinic Leader Intervention Characteristics Co-location of care teams had a positive impact on frontline experiences with Lean redesigns. Physician-Medical Assistant (MA) dyad now sit side-by-side to facilitate communication, patient care workflows. Its really a teachable moment toowere finding that the physicians are saying, Oh, you know that patient that had X, Y, and Zthis is what the diagnosis is and this is what it means, or Here are some symptoms to look out for. So, its a really good opportunity for that dyad to have teaching. - MA Supervisor

Intervention Characteristics There were challenges to accepting Lean standardization of some workflows and care processes. You have to say please trust me because if we all do it the same way and we all follow the same rulesthen the whole team can perform at an optimum level from the patient service representative, to the doctor and everyone in between, and you not only get back more time, you build a better care, you can see more patients, and you feel better about coming to work. Clinical Director Process of Implementation Engaging frontline employees in developing Lean redesigns is a critical step. [I think for Lean to be successful] make sure that the doctors and the staff continue to have a say in what happens. That's always a big concern is that people are worried things just happen from above and we're losing control. Internist When participants were involved in

developing new work processes or had greater flexibility in adapting redesigns, they reported being more willing to at least try out Lean redesigns. Inner Setting Matching implementation style to existing organizational cultures: Top-down style not as effective in clinics with democratic, non-hierarchical cultures. Micro-cultures, largely fostered by local leadership, can powerfully affect implementation efforts. Even when highly skeptical of Lean, faith in the departments leadership, and leaders willingness to be flexible and open, provided an environment where members felt that they should at least give Lean a chance. Characteristics of Individuals and Teams

Work roles and relationships between care team members were dramatically changed. Required skillsets, competence of MA as newly designated Flow Manager MD compliance with Lean redesigns affected teams ability to adopt the new workflows. Characteristics of Individuals and Teams Physician autonomy and adherence: Those most resistant to Lean believed they were already highly efficient. Some were concerned that Lean threatens their autonomy; others acknowledged they still had authority

where it matters most (in exam room): I don't feel like my work has changed so much that I'm not in control. I still decide what I'm doing with my patients. It's just that Lean presents my patients to me in a nicer way so that I can do my work better. Physician Summary of Qualitative Findings on Implementation Outer setting had most impact on frontline acceptance of Lean in principle: Market pressures, Overwhelming demand in primary care Other contextual factors played critical roles in adoption of Lean in practice: Hung DY, Gray CP, Martinez MC, Schmittdiel J, Harrison MI. Acceptance of Lean Redesigns in Primary Care: A Contextual Analysis. Health Care Management Review. 2016 Mar 2. [Epub ahead of print] Impact of Lean on System Performance Quantitative analysis of operational metrics indicating Leans

impact in primary care Performance areas examined: - Workflow Efficiency (Flow metrics) - Physician Productivity - Operating Expenses - Clinical Quality - Patient Satisfaction - Physician and Staff Satisfaction Quantitative Methods Data sourced from dashboards, billing, quality reports, Experience of Work, AMGA, and Press-Ganey surveys Generalized linear mixed models with physician-month as unit of observation (N=328 MDs employed from 2011-2014) Estimated overall impacts over time using interrupted time series analysis, non-randomized stepped wedge design Phased implementation of Lean: Projected values (counterfactual in the absence of Lean) vs. Observed values after Lean redesigns were implemented in all clinics across the system Phased Implementation of Lean Redesigns

Note: All listed Clinics (except 4 and 7) have additional satellite clinic sites that were included for analysis. Pre-Lean period Training/Implementation period Post-Lean period Workflow Efficiency (Office Visit Charts Closed < 2 hours) Pilot Clinic 3 Beta 1 Beta 2 Beta 3 Clinic 1 Clinic 4 Clinic 5

Clinic 6 Clinic 7 Clinic 2 Workflow Efficiency *p<0.05 Flow Metrics Office visit charts closed within 2 hours Electronic patient messages responded within 4 hours Prescription refills renewed within 4 hours Telephone encounters closed within 4 hours Physician Productivity RVU Metric

Projected Value (absent Lean) Observed Value (with Lean) Mean Difference (95% bootstrap) wRVU/cFTE 252.3 265.0 -13.9* wRVU/visit 1.5 1.5

0.0 wRVU: work Relative Value Unit cFTE: clinical Full-Time Equivalent RVUs restated to CMS 2014 v2 valuation wRVU/cFTE: Production per clinical FTE wRVU/visit: Service intensity per office visit *p<0.05 Clinical Quality Metrics Pay for performance clinical quality metrics for each physician over time Interrupted time series analysis on metrics that had an initial statistical difference pre- vs. post-Lean:

Coordinated Diabetes Care: A1c < 8.0% Coordinated Diabetes Care: A1c < 7.0% Coordinated Diabetes Care: LDL-c < 100 mg/dL Coordinated Diabetes Care: Nephropathy Screening Cervical Cancer Screening, Asymptomatic Women Chlamydia Screening in Women (16-20 yo) Adolescent Immunizations: Meningococcal Clinical Quality Metrics Quality Metric Projected Value (absent Lean) Observed Value (with Lean) Mean difference (95% bootstrap)

Diabetes: A1c Control < 7.0% 64.5% 67.9% 3.4%* Diabetes: A1c Control < 8.0% 35.5% 39.4% 3.9%* Diabetes: LDL < 100 mg/dL 48.1% 53.1%

5.0%* Diabetic Nephropathy Monitoring Cervical Cancer Screening 75.7% 79.9% 4.2%* 71.9% 71.1% -0.8%* Chlamydia Screening 16-20 61.7% 60.7%

-1.0%* Immunizations - Meningococcal 77.9% 69.0% -8.9%* *p<0.05 Patient Satisfaction For each physician, examined proportion of satisfaction scores > 90% for each domain and for composite overall score Patient satisfaction domains: - Access - Care Provider - Moving Through the Visit - Nurse/Medical Assistant - Handling of Personal Issues - Composite Overall Score

Patient Satisfaction Domain Project Value (absent Lean) Observed Value (with Lean) Composite Score 49.1% 63.2% 14.1% * Access 37.4% 55.4%

18.1% * Care Provider 79.0% 69.8% -9.2% * Moving through Visit 50.9% 49.3% -1.6% Nurse/MA 66.2%

68.0% 1.7% Personal Issues 69.0% 74.5% 5.5% * (proportion of 90% satisfied or higher) Mean difference (95% bootstrap) *p<0.05 Physician Satisfaction % Differences (2011 vs. 2014) By phase of implementation Lean Implementation Phase

(Time since completion of Lean redesigns) Pilot (25 months) Beta (13-15 months) All remaining (4-11 months) Staff Satisfaction % Differences (2011 vs. 2014) All primary care clinics system-wide Summary of Lean Impacts Topic Workflow Efficiency Conclusions Increase in timeliness of completing 3 of 4 workflow measures: office visit chart closures, medication renewals, telephone responses. Physician Productivity Higher wRVUs generated per physician per month. No change in wRVUs per office visit (service intensity)

Operating Expenses Lower total operating expenses (including staff compensation, and drugs and supply costs) standardized per tRVU. Not significant at p<0.05. Clinical Quality Improvements in coordinated diabetes care metrics, no change in preventive screening metrics, and decreased meningococcal immunization among adolescents. Patient Satisfaction Higher satisfaction overall and in specific domains, including access to care and handling of personal issues. Lower satisfaction with interactions with care providers. Physician Satisfaction In pilot and beta clinics: Higher satisfaction overall and in specific domains, including

time spent working and relationships with staff. Lower satisfaction overall in last phase of gamma clinics to implement Lean. Staff Satisfaction Higher satisfaction overall and in specific domains, including credible leadership, employee engagement, growth / development, connection to purpose, healthy partnerships, empowerment and autonomy. Hung DY, Harrison MI, Martinez MC, Luft HS. Scaling Lean in Primary Care: Impacts on System Performance. American Journal of Managed Care, Forthcoming March 2017. Conclusions Implementation context matters - Process of scaling across multiple sites - Frontline engagement - Alignment with internal clinic environments Overall, beneficial effects of Lean redesigns on performance without harm to clinical quality Using Lean techniques to redesign care delivery - Attention to flow - Change management: involve providers in design and also results

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