North America Lean Practitioners Conference Fall 2017 Walnut Creek, CA. Lean Transformation. A CFO s Perspective

Transcription

1 North America Lean Practitioners Conference Fall 2017 Walnut Creek, CA Lean Transformation A CFO s Perspective Andrew Wampler, CFO Pardee Hospital System Sean Langan, Simpler Lean Engineer PARDEE HOSPITAL

2 Topics Learnings From Large Health System Pardee Hospital An Accelerated Approach 2 9/29/2017

3 Lean CFO Financial Improvement/Baldrige Journey Lean journey began with new strategic plan in 2011 to drive fixed cost out of system as utilization declines Site visits to Virginia Mason and Thedacare Partnered with Simpler to start lean transformation Led initial Value Stream Analysis and Events within Revenue Cycle 3 9/29/2017

4 Health System in SE Located in TN, VA, KY, and NC 13,000+ Employees 1,000+ Physicians 650+ Rev. Cycle Employees $950M Net Revenue Business challenge Engaged Simpler in 2013 to improve their complex processes and adopt a lean methodology. Below some of the main issues Revenue Cycle was facing at that time: 7 years of rapid facility integration to corporate model 8 core platforms and multiple bolt ons Combination of physician and facility back end operations Transition of Scheduling from Marketing 5 big bang system conversions Limited team engagement Business Benefits Delivered Solution $74 M Cash flow (AR) $31 M Denial write offs 100% RC employees participated in Lean A process improvement methodology linked with strategy Over 100 Rapid Improvement Events (RIE) 3% Outsiders participated in lean events 6% Redeployment thanks to process improvements 34x ROI* Focus on patient access, encounter, and billing Fast pace improvement (3 events per month) Emphasis on management to daily improvement (DIBS) Team member driven Process metrics with alignment to TPOC metrics Leadership engagement through hands on involvement/coaching

5 Revenue Cycle Operations Non Health System Providers Regulatory Environment Physician Documentation Commercial Payers Facility Corporate Leadership Scheduling Financial Clearance Registration Health Information Management Coding Billing Cash Posting Recovery Ambulatory Clinic Based Leadership Ambulatory Corporate Leadership Physician Clinics Reserve Reporting Case Management Charge Entry 5 9/29/2017

6 Operational Steering Team First VSA Refresh Revenue Cycle VSA Executive Steering Team Operational Steering Team Operational Steering Team Front VSA Scheduling, Financial Clearance, Registration, Self Pay A/R and Uncompensated Care management Middle VSA Charge Capture, Coding/HIM, Clinical Documentation, Utilization Review Back VSA Claims Processing, A/R Management, Transaction Posting, Recovery Management Process Owner(s) VOS Facilitator Process Owner(s) VOS Facilitator Standard of Work Repository and Implementation Training Strategy and Support VSA Strategic Planning, Managed Care, Chargemaster, Finance Process Owner(s) VOS Facilitator 6 9/29/2017

7 Overall Lessons Learned Need engagement at all levels Make decisions using data Shared accountability of processes Big difference between SOW and Policies and procedures Using A3 thinking vs fire fighting Education for other organizational leaders Measurable results coming out of event weeks 7 9/29/2017

8 Key Drivers and Tools Continuous Improvement Culture Change from management mindset to leadership approach Elimination of top down directives Empowered team members to make decisions Subject matter expert involvement Migration from fire fighting to A3 problem solving DIBS boards and tickets to identify gaps 5 whys to get to root cause Paretos for data driven results 8 9/29/2017

9 Key Drivers and Tools Road Map Visual of big picture Living and breathing document Shows the pace and rhythm Helps VST prioritize Alignment of metrics bottom up: DIBs, Events, and VSA 9 9/29/2017

10 Key Drivers and Tools DIBS 2.0 Daily huddles Metrics specific to the process Alignment to higher level Lag Metrics Team member driven Suggestion system Creative themes 10 9/29/2017

11 Pardee Hospital UNC Health Care Pardee Hospital is a not for profit community hospital that was founded in 1953 and is managed by UNC Health Care. It is the first and only hospital in North Carolina to be accredited with the International Organization for Standardization (ISO 9001:2008) for quality health care standards. We are licensed for 222 acute care beds and are the second largest employer in Henderson County. We have several locations separate from our main campus, including a comprehensive physician practice network, two urgent care locations and five orthopedic clinics. 11 9/29/2017

12 Pardee Hospital Value Streams TPOC Feb Surgical Services March 2015 Scheduling 1 st Case On time starts Turnovers PAT Day Surgery 6S CSR Tray Accuracy PAT (2 nd pass) Turnovers (2 nd pass) Pre op Patient Flow Post op Patient Flow CSR 6S Case Cart Accuracy Decontam Process Emergency Services Nov 2015 Room Standardization Room Turnovers ESI 4/5 Flow Process ED to Inpatient Behavioral Health Processes Clinical Processes (Room to Dispo) Imaging Turnaround Lab Turnaround Discharge Process Inpatient Jul 2017 New Value Streams Physician Network Nov 2017 Revenue Cycle Jan 2017 Surgical Class Non procedure Registration Physician Documentation 7 Areas doing MDI No Auth Denials OP Surgery Liability Claim Process Optum Denials (ED & Direct Admits) Rev Cycle Flow Cell Joint Camp Med Necessity OP CMS Repayment Late Charges 12 9/29/2017

13 PARDEE HOSPITAL LEAN TRANSFORMATION Business Challenges Affiliation with UNC raises performance expectations & threatens autonomy. Growing orthopedic services lines (added 9 surgeons) Opened OP Cancer Center EPIC & Lawson Implementation High AR Days High denial write off Lack of Engagement Business Benefits SURGICAL SERVICES 1.5 Years EMERGENCY DEPARTMENT 1 Year 52% to 76% 1 st Case On Time 5.41% to 2.1% LWBS 85.9 to 94.1 Press Ganey Top Box > 35 to 29 Min Door to Doc > 35 to 12 Min Door to Room 3.7% to 3% Same Day Cancel 305 to 267 Min Admitted LOS 160 to 144 Min Discharged LOS ROI $898, Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 REVENUE CYCLE 6 Months $2.5 M Cash flow (AR) $341 K Cost to Collect 40% RC employees participated in Lean $104 K to $72 K / Week Denial Write Offs $ 2,841,000 10X ROI

14 Pardee Operating Model Vision & Strategy 1 Organization Aligned to Breakthrough Performance Create & communicate long term vision Set double digit improvement goals for HD, Q, T, C, & G Create long and short term strategy deployment plan Drive Value streams alignment with and continual support of strategic plan Vision & Strategy Infrastructure Right People, Right Training, Right Visuals Visual Management infrastructure. Everyone: Sees, Knows, Understands 2 3% Capacity dedicated and embedded resources. Internal Lean Coaches & Engineers Everyone trained in the tools and principles of Lean Value Stream Improvement Develop Leaders All departments in value streams n/10 event cadence (+/ with MDI) VS A3, Events, & Projects aligned with TPOC, scope, prepped, executed, and sustained. Staffing to demand based on our work content. Value Stream Improvement Infrastructure Develop Problem Solvers Daily Improvement Daily Improvement Leadership Standard Work Go & See process Coach to standard work & demand Develop problem solvers Conversations: daily, tiered, structured 14 9/29/2017

15 Revenue Cycle Accelerated Approach Fast gap analysis of current state Time to first event & MDI board <2 Months! Full Time Gemba Coach & Lean Engineer 7 MDI Boards & Huddles VSI MDI JAN FEB MAR APR MAY JUN JUL Flow Cell Gap Analysis RIE#1 Surg Procedure Documentation RIE#2 Non Surg Proc Documentation RIE#3 Registration # of Areas doing MDI Billing Coding Rev Integrity Insurance Verif. Registration Ins. Follow Up Customer Service RIE#4 Inpatient Documentation KAMISHIBAI 15 9/29/2017

16 Pardee Operating Model Obeya Live Value Stream Map RIE Minimal Setup VSA A3 Board St Work Board & Obeya Board Lean Transformation Specialist Standard Work 16 9/29/2017

17 Pardee Operating Model VS Steering Team Meeting Value Stream Improvement Cycle Time: 30 Min Review dashboard, Kamishibai board, and event & project pipeline. Daily Improvement Cycle Time: 30 Min Each Process Owner highlights their Flow Cells performance, improvements and help needed 17 9/29/2017

18 Pardee Operating Model Mission Control Improvement Pipeline Dashboard Kamishibai 18 9/29/2017

19 Pardee Operating Model Live Value Stream Wall STANDARD WORK Process owner to update every Tuesday by 1030 AM as it will be reviewed during the Value Stream Steering Team meeting at 11 AM. Write the numbers in green if it went down and red if it stayed the same or went up. FLOW CELL GROUP: ACCOUNTS RECEIVABLE DAYS 2.1 $ REVENUE INTEGRITY DOLLARS 3,440, /29/2017

20 Pardee Operating Model MDI BILLING MDI Huddle 2/wk for in person problem solving Use Google Sheets to collected Pareto data Problem solving lanes 20 9/29/2017

21 Pardee Operating Model One Point Lessons Flow Cell 1PL Posters & Cards 21 9/29/2017

22 Pardee Operating Model 6S 6S Project has been a great way to get our team members involved early on as 6S is quick and can be done in small increments. 22 9/29/2017

23 Registration First Model Cell Staffing to Demand Standard Work Next Patient Andons Workplace Organization 23 9/29/2017

24 How We Leverage Technology Virtual Boards What is a virtual board? It s a tracker of performance, barriers, problem solving and/or reflection that resides on the Cloud. Tools like Google Sheets (free) and Excel Online are most commonly used for this purpose. Why? Great for people who: Cannot practically get together in person like for example Coders who are often geographically dispersed. Work at a desk on a computer which would make it inefficient to require them to leave their office to go record their production & barriers on a Pareto. Even if they would record this on a paper tracker on their desk, the manager/supervisor would still have to manually converge the individual trackers on the board. CAUTION: DON T to replace in person problem solving!! 24 9/29/2017

25 How We Leverage Technology Virtual Board Examples Registration Andons Cash Posting Hourly / Daily Production Paretos Red Tag Area 25 9/29/2017

26 How We Leverage Technology ROBOTICS PROCESS AUTOMATION In Revenue Cycle, there are many people working processes that involve very monotonous, non value added key strokes, time that could be better spent coaching clinical staff on documentation quality at the source, Patient financial counseling to patients, etc. In a partnership with IBM & Simpler, we embarked on an A3 to test the power of Robotics Process Automation. We chose the process of Notification Of Admission (NOA0 to Blue Cross Blue Shield. Impact: free up 425 hours of productive time per year & reduce $61 K of NOA based denial write offs! Key to success was creating highly detailed process maps for programmers: 26 9/29/2017

27 Cognitive RCM: where intelligent automation meets insightful engagement Stages of benefits and value for enhanced decision support Business Intelligence Lean Practices Eliminate waste Remove defects, delays and rework e.g., PPI mgmt tool, Kanban, A3 Retrospective Robotic Process Automation (Rules-based) Extensible and adaptive prebuilt process object libraries Global robotic command center and dedicated SMEs IBM & partner resilient and secure, virtualized infrastructures e.g., BPM with enhanced business rules engine Predictive & Prospective Autonomic Process Automation (Knowledge-based) Extension of RPA by applying insight-driven knowledge and learning from experience Continuous monitoring of process environment Automating common obstacles with unstructured data e.g., Watson Policy Manager (WPM) enabling automation of key decision points Cognitive Cognitive Automation (Artificial Intelligence) Autonomous decision-making ( reasoning and remembering ) New insights and data discovery ( learning ) Personalized, conversational support ( engagement ) Insight-driven interactions e.g., Industry-specific virtual assistants, Cognitive Buy Assistant Blockchain RCM Shared Services Platform As A Service, Outcomes-based Business Model Simple Transactional Data Structured Data / Simple Rules Unstructured Data / Complex Rules Human Technology partnership 27 9/29/2017

28 Kamishibai Process Sustainability Biggest pitfall is long term process sustainability. Kamishibai is essential to ensuring that we constantly cycle through all our standard work. 28 9/29/2017

29 Revenue Cycle The Next Frontier Move from Silos to True Flow Cells Schedule Insurance Verification Coding Case Management Billing Insurance Follow Cash Posting Flow Cells Dedicated to Units Scheduling Insurance Verification Coding Case Management Billing Insurance Follow Up Cash Posting Jan 2017 RIE: Ortho Joint Camp Rev Cycle Flow Cell Target: reduce AR days from 37 to 22 days!!!! Upon Patient discharge, all claims cleanly billed, copays collected and customer clearly understands remaining financial responsibility. 29 9/29/2017

30 Pardee What s Next? Start up of value stream #5: Physician s Practice Leadership Standard Work Staffing to Demand Leadership Standard Work Model Hospital within UNC and Industry Leverage as Lean teaching hospital Benchmark for UNC and other community hospitals 30 9/29/2017