For many of us change is a difficult process. In organizations like healthcare it seems to advance at a snail’s pace sometimes. There is a need for change in healthcare, most agree, though we would be hard pressed to agree upon the changes needed. One incentive for change is pay-for-performance programs now beginning in several areas. I would like to describe a couple that affect primary care physicians and then give a few suggestions as to how to adopt changes to take advantage of these programs. Even if you are not in a primary care physician program, the methods suggested for change will be helpful, I believe.

In 2006 Medicare plans to institute a pay-for-performance program at the primary
care physician level. Right now a model is being tested and seems to be doing quite
well. In several states Blue Cross Blue Shield organizations are testing pay-for-
performance programs. Here in West Michigan, Priority Health, a healthcare insurer,
has promoted such a program for over five years. How does this work, you may
ask? Priority Health, for example, funds the program for each of its patients a set
amount. Doctors who meet a requirement of the program for a patient are rewarded
with extra money for that patient. Hence, with many patients the income for the
practice can be boosted considerably. The fact is that many are not rising to the
opportunity. With planned cuts in Medicare reimbursements over the next few years,
this source of income cannot be ignored! Healthcare programs need to change, no
matter how difficult.

The impetus for change should rest with the leadership of an organization, although
the change should not be the sole responsibility of the leaders. Representatives
from all parts of the organization should be involved. Once the need for change in a
process is agreed upon, either because of extra revenue from pay-for-performance
programs or other agents or data that positively affect the bottom line, leaders
should convene a task force to plan the change. With input from all, leaders should
map the process as it currently exits and then should make a new map of how they
would like it to be to incorporate the positive changes. The new procedure should
be standardized for all to adopt.

How do you go about adopting these changes on a daily basis? This is probably the
hardest part. Because humans learn in a variety of ways, it will take a variety of ways
to implement the changes. The implementation of the changes should be based
upon the learning styles of the individuals involved. Let me provide an example
using the Medicare program. A patient who enters the Medicare program is entitled
to a paid initial physical. A primary care physician should take advantage of
this. Many don’t. If I were the manager of such an office, I would remind my staff
who set up appointments to be aware of this fact. I would remind them at regular
staff meetings. I would post visible reminders in the office. I might even have a
message flashed on the computer screen once in a while. Then I would review the
appointments of patients who have become Medicare qualified and see how many
had their initial physical or were booked for it. I would adjust my methods to remind
staff of the need for such examinations and continue to improve on this until the
office achieves 100% compliance with the goal.

Booking the exam is not the only needed change. Doctors who perform the physical
must accomplish examination details and actions laid out by Medicare. Hence, to be
paid for the exam, each doctor must adhere to the exam details. I would help the
doctors accomplish this in a variety of ways, depending on the doctor’s learning
style. For example, a checklist of the exam details might be included in the patient
history folder when the exam is performed. That way the doctor will not miss any
steps. As the leader of the change, I would check with billing to see that all the
steps were performed and adapt new approaches or reinforce existing ones to see
that the changes are accomplished 100% of the time.

Changes such as these should be a part of a continuous quality improvement
program at every healthcare provider organization. Let me quickly review the most
important steps. First leaders should identify the changes needed. Then, the leaders
should convene a committee of all affected staff to develop how to accomplish the
change. Once the staff agrees upon the approach, the leaders should develop ways
to implement the change on a daily basis adopting methods that incorporate
learning styles of affected individuals. Then, they should continually analyze the
progress of the changes and make necessary adjustments until the goals are
accomplished. They should then audit the changes occasionally to be sure that the
organization doesn’t fall back into old habits.

I believe that adopting such a change process will dramatically help at your site. You
will see savings in time, increased patient or client health and satisfaction, as well as
an improved bottom line!

Donald Bryant, certified quality engineer, writes “Making Good Healthcare Better” a
free monthly ezine for healthcare providers who want to dramatically improve
patient health, improve the bottom line, and make work more rewarding,
guaranteed. To find out more, visit http://www.bryantsstatisticalconsulting.com

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Quality improvement should be a system-wide initiative. Many healthcare facilities
think of quality only as it applies to the clinical side. They concentrate on outcomes
defined by accrediting bodies such as JHACO. Many businesses are like this
too. However, the best organizations use quality tools throughout their
organization. I want to show you the benefits of doing so.

As a healthcare professional would you even think of just treating one part of the
body to keep a patient healthy? For instance, do you think that just by concentrating
on the heart that you can keep the rest of the body healthy? Certainly
not! Healthcare professionals know that to keep a body and mind healthy they must
concentrate on the whole body. That’s why we give patients regular physicals.

A healthcare facility or site is much like a human body. All parts much function well
to insure positive outcomespatient health, a good bottom line, and time and staff
to get things done. A hospital is more than just the doctors and nurses. The
administrative staff and all other supporting staff are important too. For instance, in
a recent issue of Quality Progress an article highlighted a change in food delivery
which greatly impacted profit and patient satisfaction. The hospital decided to let
patients order food from a menu much like any commercial restaurant at any time
convenient to the patient and not too unreasonable for the hospital. They
responded to patient needs and wants and saved money doing so.

If your site is a family doctors office, do you think that the only important functions
are those provided by the doctors and nurses? What do you think a patient would do
if he or she got excellent delivery of primary health treatment and prevention but
had a horrible experience with billing? That patient might very well end the
relationship with your facility.

Research has shown that the key to profits is customer loyalty. One of the key
ingredients of customer loyalty is quality of service and product delivered by
satisfied employees. That means that every facet of an organization is important in
delivering a service or product.

So how do you get started?

–Leadership is a key ingredient. Leaders at all levels must support system-wide
quality.

–Gather information on quality improvement ideas from all areas and staff. No
one’s ideas are unimportant.

–Form cross-sectional teams to solve the important problems that you have
identified.

–Gather baseline data about the process as it exits now so you know when you are
improving and by how much. Monetary measures are important.

–Make a detailed plan that all team members can agree upon and educate the staff
about the tools needed to implement the changes.

–Implement the changes and measure your success.

–Make the new, improved methods standard operating procedures.

Many of the ideas above come from Lean Healthcare ideas and other quality
improvement initiatives, such as Baldrige and Six Sigma. The CFO of one local
hospital with whom I spokeMetro Hospital of Grand Rapids, MIstated that Lean
was one their primary tools and that it had made an enormous impact at their
sites. Metro was even recognized recently in a national publication of The Institute
for Healthcare Improvement as a leader in quality.

Implementing quality improvement throughout an organization is a difficult task.
For many, this approach is a radical cultural change. Such changes fail without
commitment from leadership and steady and firm hand guiding the changes. I
suggest that you start small and spread the initiatives methodically throughout your
organization. At each step demonstrate to all the benefits for the organization and
to the individuals. Doing so will ensure that many will buy into the changes and
commit to continuing quality improvement. I know of some organizations, which
have gone through several Lean training initiatives but have failed to maintain it
system-wide for a variety of reasons. They end up losing many opportunities to
improve the bottom line, increase client loyalty, and improve employee satisfaction
in a job well done.

Donald Bryant helps healthcare providers meet their challenges and writes
“Making Good Healthcare Better” a free monthly ezine for healthcare
providers who want to dramatically improve patient health, improve the
bottom line, and make work more rewarding, guaranteed. Go now to
http://www.bryantsstatisticalconsulting.com to get a free article with tips you can
use to start making improvements immediately and to learn more about Lean Healthcare.

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In quality improvement engineering there are many tools. I would like to illustrate a few and show how they can apply to healthcare. I will be using tools taken from Lean Manufacturing, an approach used at Toyota Motor Company for many years now. These tools are easily adaptable with a bit of imagination to healthcare. I am not proposing that all healthcare should blindly adopt Lean as the new “flavor of the month,” but if some of the tools fit your site well, then use them. From my experience, the best progress in quality at a site is in the identification and use of quality improvement tools that can be mastered by the employees of the site. There is no use in being a Jack-of-all-trades and master of none.

Two tools that seem to go hand in hand are 5S and Point of Use Storage. 5S is sort, set in order, shine, standardize and sustain. In the most recent issue of Quality Progress (American Society of Quality’s magazine) these tools were applied to storage areas. A storage area should only contain items that are useful to tasks that are performed nearby. For instance in an examination room there should be a good assortment of bandages, but it probably doesn’t make sense to store printer ink in the exam room. This is an example of point of use storage. Further, any storage area no matter the size should be well ordered. You don’t want to have too many of any one item; it is better to have in stock what is needed for a day or two and restock as needed. That way, you can have a wider variety of items in the storage area and will waste less time going to look for a supply when it is needed and it isn’t nearby.

Besides having the right amount of items in a storage area, you should have it arranged so that the most frequently used items are easiest to access. A way to make sure that this order is maintained is to have a diagram in the storage area showing where things are located. That way, whenever restocking occurs, items will be placed in the right place so anyone who uses the supplies can easily find them. With a diagram of the work area a person using it for the first time will be easily able to locate an item. A good rule is that anyone should be able to find any item in 30 seconds or less.

Finally, in arranging a storage area, be sure to get rid of any outdated items. If an item is rarely used in activities near that storage area be sure to transfer it to the point where it would be most useful or if no one uses it, dispose of it. Of course, this arrangement of stored items will only be successful if most everyone will work at maintaining it.

Another useful tool in lean is to eliminate wasted effort. One glaring example that I have seen is the amount of time nurses have to expend in getting prescriptions refilled for patients at primary care sites. The nurses and other representatives from the staff should examine the process of refilling patient prescriptions by drawing a diagram of the process (value stream mapping) and measure how much time each step takes and which are really needed in the process. I bet that some steps can be eliminated and thus time saved. One suggestion that I have is for prescriptions that are used over a long period of time, such as hormone replacement medications. Why not move the patient into ordering 3 months of the prescription at a time through a mail order pharmacy? It may take a bit of effort to move a patient into this habit, but is will save a lot of time in the long run for an office and will free nurses to do much other needed tasks. The patient will also be happier as they can usually save money by ordering in this fashion. My wife and I order all our recurring prescriptions this way and easily save over $200 per year.

Many in healthcare think that these tools are not useful to them. Recently I was talking to someone about using Lean principles in their office. This person thought that because health plans had so many rules applying to such things as coding and billing and other documentation that there was little room for improvement. To me this is an illustration of lack of communication among the various people on staff. If a team was formed of representatives from the staff and the above tools examined I know that the team could find many ways to find savings in time, money and effort similar to the ones that I chose to illustrate. Once the processes are identified and standardized, then the site can continue seeking ways to further improve in a process of continuous quality improvement.

Donald Bryant helps healthcare providers meet their challenges and writes
“Making Good Healthcare Better” a free monthly ezine for healthcare
providers who want to dramatically improve patient health, improve the
bottom line, and make work more rewarding, guaranteed. Go now to
http://www.bryantsstatisticalconsulting.com to get a free article with tips you can use to start making improvements immediately and to learn more about Lean Healthcare

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