Creating a Culture of Excellence at USF Women's

Creating a Culture of Excellence at USF Women’s Health

WCBF Lean Six Sigma Healthcare SummitMay 2011

Louis C. Rhodes

Purpose: Introduce USF Women’s Health and its journey of transformation over the past 5 years

Learning objectives:• Identify cultural elements that support

transformative efforts• Describe application of Lean Six Sigma

techniques across various opportunities• Select actions to improve cultural acceptance of

transformation

Purpose and Learning Objectives

2

• Why does Lean Six Sigma work in some organizations and not in others?

• How does cultural acceptance and the ability of an organization to embrace change affect success or failure?

• How do you develop a continuous process improvement culture?

• What organizational change and development tools can be utilized to overcome barriers and resistance to change?

Key Questions/Issues

3

• Administrator, New York University (Department of Obstetrics and Gynecology)

• Graduate of United States Military Academy (BS Management – Engineering) and Xavier University (MBA)

• General Electric Certified Black Belt and Master Black Belt in Six Sigma and Lean

• Eleven years experience in Six Sigma, Lean, and Change Management roles:

• Two years chemical industry (Millennium Chemicals)

• Four years in healthcare equipment and service delivery (GE Healthcare)

• Five years academic healthcare (USF Health and NYU School of Medicine)

• Expertise in curriculum development and skills transfer to clients

Lou Rhodes, MBA, MBB

4

11:15 – 11:45

11:45 – 12:15

12:15 – 12:45

12:45 – 2:00

2:00 – 2:15

Agenda

Introduction

Who will get us there?

Where are we headed?

How will we get there?

Summary and questions

5

• Please introduce yourself including:• Name• Position

• As a group, describe expectations for this session.

Introductions and Expectations

6

• Housekeeping:• Restrooms• Safety

• Ground rules:• Informal environment• Interactive exercises• Break individually as needed• Maintain speed• Limit cell phone use• Anything else?

Housekeeping and Ground Rules

7

• “What does culture mean to you?”

Exercise: Defining Culture

8

• Corporate culture: A blend of the values, beliefs, taboos, symbols, rituals and myths all companies develop over time*

• The way people think• Actions and beliefs• Acceptance and non-acceptance of performance

* - From Entrepreneur.com

What cultural challenges do you experience?

Cultural Transformation

Current Culture

Desired Culture

Time and Effort

You are here!Gap

How do we close the gap?

9

Path: Operational management and

improvement

Elements of CulturalTransformation

10

People: Leadership and

change management

Plan: Strategy development and

execution

Where do Lean Six Sigma experts fit in?

Background of USF Women’s Health

11

• No state income tax• Reliance on real estate development as primary

industry and real estate taxes for primary source of revenue

• State university system reliant on public funds• State tuition levels held at very low levels• Continued pressure on reimbursement rates and

payer mix

Florida Government andEducational Environment

12

• Mission: To improve life by improving health through partnership, research, education and healthcare

• 3,500 team members of educators, staff, physicians, researchers

• Over 420 physicians, 135 allied health, and 70 nurse practitioners

• 2 new out-patient buildings with imaging and an ambulatory surgery center

• 500,000 outpatient visits• 33% of Best Doctors in Tampa Bay• $350 million enterprise• No university hospital

USF Health Overview

13

• 40 – 50 faculty (physicians)• 60 – 80 staff (managers, nurses, medical assistants,

administrative assistants)• Multiple practice locations and commitments:

• 2 out-patient offices• 5 out-patient clinics• Labor and delivery coverage (24/7)• Residency coverage

• ~14,000 out-patient visits and 4,000 deliveries (2005)• Full OB/GYN service availability and access to other

specialties• Limited focus on efficiencies, service, or brand image

Department of Obstetrics and Gynecology (USF Women’s Health)

14

People: Leadership and Change Management

15

• Focus on clinical training in medical and nursing schools

• Progression from clinical to leader responsibilities• Growing complexity and integration of healthcare

system• Recognition of need for:

• Leadership skills• Emotional intelligence• Business skills• Professionalism

The Need for Leadership inMedicine

16

Leadership Institute at USF

17

• Top talent• Progressio

n planning• Selection

process

• Top talent• Progressio

n planning• Selection

process

• Tailored classes• Personality evaluations• Mentoring• Team-based system

level projects

• Better leaders

• Bench strength

• Project delivery

• Better leaders

• Bench strength

• Project delivery

• Classes:

• Creating high performance teams

• Communication and influence

• Conflict management

• Effective coaching and counseling

• Strategy mapping

• Financial acumen

• Effective problem solving

• Systems thinking

• Streamlining flow

Content

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• Evaluation:• Myers-Briggs testing• Learning connection

inventory• Team based project:

• University level project• Diverse team• Operational mechanisms to

manage and monitor delivery

• Mentoring:• Personal mentor• Project mentor

• ~80 Graduates:• Promoted to Chairs, Assistant

Deans, and Associate Deans• Improved leadership skill sets• Increased knowledge of university

and associated systems• Delivered high impact projects in the

areas of:• Customer service improvement• New service launches• Throughput improvement• Faculty mentoring

Impact

• USF Women’s Health:

• 5 graduates• Interim Chair,

Chief Medical Information Officer, Assistant Dean

• Successful practices

19

Change Management

Q x A = EQuality of the Solution times Acceptance of the

Solution equals Effectiveness of the Solution

• Recognition of the need for treating change as a system and process

• Employment of tools and approaches to understand motivations

• Development of strategies to increase support for initiatives

20

Setting the Vision

Mobilizing Commitment

Sustaining Improvement

Creating the Need

Monitoring Progress

Unfreezing Stage

Change Stage

Refreezing Stage

• Opening people’s minds to change

• Stating the “good” that will be

• Bringing people along

• Eliminating slippage

• Confirming delivery of the “good”

Foundation: Leadership and Reinforcing Systems

Change as a Process

21

Exercise: What do physicians want? Not want?

22

• Respect

• Information

• Input on decisions

• Things-that-work

• Incentives

• Presence

• Inefficiency

• Time wasters

• “Small-mindedness”

• Bureaucracy

Want Not-Want

• Alignment of goals and incentives:• Tie of pay to financial performance of the practice

• Transparency:• Established metrics• Department reports• Individual reports

• Additive interactions with physicians and staff• On-site availability and regular communication• “Speaking their language”• Participation on initiatives and projects

Change Management at USF Women’s Health

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Plan: Strategy Development and Execution

24

Strategy Cycle

EnvironmentEnvironment

Filter

Metrics

InitiativeInitiative

AnalyzeAnalyze DefineDefine AlignAlign LaunchLaunch ManageManage MonitorMonitor

Strategy Team

Deliver

Communicate

Develop Implement

Initiate

OpportunityOpportunity

Opportunity

Resources

25

26

STAKEHOLDERSWho can help or

hinder us

STAKEHOLDERSWho can help or

hinder us

ENVIRONMENTWhere have we

beenWhat is around usWho do we serve

ENVIRONMENTWhere have we

beenWhat is around usWho do we serve

MISSIONWhy we exist

VALUESWhat’s important to us

VISIONWhat we want to be

MARKET DIFFERENTIATORSWhat makes us different

STRATEGIC OBJECTIVESOur game plan

KEY PERFORMANCE INDICATORSHow do we know we have gotten there

DESIRED STRATEGIC OUTCOMES

STRATEGIC INITIATIVESWhat we need to do

ACTION PLANOur specific task plan

Abstract

Concrete

Strategy Development

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Exercise: Threats vs. Opportunities

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• Reduced funding for university

• Continued reductions in reimbursement

• University bureaucracy and slow speed of decision-making

• Loss of talent

• Leverage multi-practice availability

• Increase transparency on performance

• Manage brand image

• Increase operational efficiency

• Improve service delivery

Threats Opportunities

Customers What are their needs?What do we give them? Need to give

them?

High Risk Patient to Low risk patients

• Quality of Life• Health• Healthy Babies

• The best most comprehensive care

Disadvantaged Payers

• Compassion• The best care: Quality of Life,

Health, Healthy Babies

• We are “IT” in town• The best most comprehensive care

Referring Physicians

• Efficient quality care• Follow through• Expertise - experiences

• Continuum of subspecialty care• Experts• Quality• Efficiency? Fast turn around?

Medical Students/ Residents/ Fellows

• Continuum of care/learning – From high to low risk

• The best most comprehensive care• Experts - the best trainers• Exposure to continuum of care• Cutting Edge

Donors

• Meaning• Individual care • Affiliation with Winners• Make a difference

• 1st in outcomes, innovation, and care• Being winners• Experts• The best trainers and providers• Cutting Edge

Customers and Needs

• Provide local, national and international leadership in women’s healthcare, education, and research

• Deliver comprehensive, full spectrum healthcare services to women in a friendly, efficient, timely, effective, and compassionate environment

• Graduate leaders from our residency, fellowship, and faculty programs

Mission and Vision

In 2015, an article is written about USF Health OB/GYN including the following points:

• Top 10 programs ranked in U.S. News and World Report• Top 20 NIH funded programs• Delivering cutting edge comprehensive women’s healthcare services• Leading the way in friendly, timely, effective, efficient, and profitable

care• Leading outcomes in state

In 2015, an article is written about USF Health OB/GYN including the following points:

• Top 10 programs ranked in U.S. News and World Report• Top 20 NIH funded programs• Delivering cutting edge comprehensive women’s healthcare services• Leading the way in friendly, timely, effective, efficient, and profitable

care• Leading outcomes in state

29

Recognized Leaders in

Clinical Care

Efficiency and Customer Service

Excellence

Cutting Edge • 1st in New

Procedures• 1st in Discovery• 1st in Efficiency• Comprehensive

care

Profitability• Entrepreneurial

Academic Model• Cost Efficiency

• Recognized Leaders in Clinical Care:• Comprehensive services• Leading outcomes in state

• Cutting Edge: • University – Innovation – cutting

edge• Leadership being 1st

• 1st Outcome• Process Engineering

• Efficiency & Customer Service Excellence:

• Customer satisfaction (Patient, Referring Physician)

• Responsiveness and communication

• Thank you – confirmation• Attention to details• “Flawless execution”• “Service recovery”• Leadership being 1st

• Entrepreneurial:• In-house Management (Creativity)

• Recognized Leaders in Clinical Care:• Comprehensive services• Leading outcomes in state

• Cutting Edge: • University – Innovation – cutting

edge• Leadership being 1st

• 1st Outcome• Process Engineering

• Efficiency & Customer Service Excellence:

• Customer satisfaction (Patient, Referring Physician)

• Responsiveness and communication

• Thank you – confirmation• Attention to details• “Flawless execution”• “Service recovery”• Leadership being 1st

• Entrepreneurial:• In-house Management (Creativity)

Strategic Objectives

30

Strategic

Objectives

Short Term

FY2009 Initiatives

Mid Term

FY2010 Initiatives

Long Term

Initiatives

Recognized Leaders in Clinical Care

• Increase marketing efforts

• Publish outcome metrics

Cutting Edge• Grow Ultrasound

Services• Leverage EHR

• Improve Research processes

Efficiency and Customer Service

• Improve internal referrals

• Improve service levels

• Improve scheduling/call system

• Improve referring MD communication

Profitability• Improve charging• Improve coding

• Increase rates of reimbursement

• Create extra sources of revenue

Branding

Scheduling

Service

Strategic Initiative Timing

31

Event Participants Review Items Timing

Faculty Meeting

• Faculty, Leaders

• Strategic Initiative Report

• Quarterly (some metrics reported on a semi-annual basis)

Individual Meetings


• Profit and Loss Review

• Semi-Annual

Department Celebration


• Accomplishment Review

• Annual

Operating Mechanisms

32

Path: Operational Management and Improvement

33

Initiative Focus

34

• Initiatives at USF Women’s Health:• Improve

Generalist scheduling

• Brand USF Women’s Health

• Launch STEP (Strive to Excel Program) Team

OutcomesService

Excellence

Cost (or Profitability

35

Revenue Business Levers: Clinical Operations

Profitability = Revenue – Cost

Revenue = Direct Patient Revenue + Contracts + Research + Grants

Direct Patient Revenue = (Clinical Charges + Professional Charges) * Collection Rate• Increase collection rate • Improve payer mix• Increase reimbursement rate

Clinical Charges = Appt./Session * Sessions * $’s/Appointment * Appt. Fill Rate • Increase

sessions• Improve service mix• Increase billing

accuracy• Increase procedure

conversion rate

• Improve scheduling• Reduce no-shows• Improve referrals• Promote practice

Appt./Session = Session Length / Time/Appt.• Utilize all

available hours• Extend hours

• Eliminate constraints• Adjust practice

• Increase appts. per session

• Set minimum quantity

• Increase outreach to service consumers

• Increase development efforts

• Increase outreach to research consumers

• Increase conversion to procedures

35

Cost Business Levers: Clinical Operations

Profitability = Revenue – Cost

Cost = Salary and Benefits + Room Charge + Equipment Cost + Supplies

Salary and Benefits = Physician S&B + Clinical Staff S&B + Admin Staff S&B

• Maximize efficient use


• Eliminate obsolete supplies


• Eliminate unused equipment/contracts

• Concentrate on revenue support

• Reduce wasted activities

• Leave empty positions unfilled

• Reduce positions




Other salary and benefit actions:• Freeze salary increases• Reduce salary levels• Reduce benefits

• Maximize revenue production




36

Purpose and Relevance:Generalist Scheduling

• Purpose: To review the process for assigning OB/GYN Providers to service areas

• Relevance: Based on analysis, there are opportunities to:• Reduce Patient bumps• Level Provider demand on clinic resources• Increase visibility and availability of additional slots for

Providers• Decrease rework in clinical operations and systems support

37

Dr. Lynch requests scheduling issues from Faculty

IDX prints bump list

Faculty calls Dr. Lynch with scheduling issues

Provider profile of available days

Dr. Lynch identifies/ reviews contractual commitments

Dr. Lynch develops Generalist grid (providers and schedule)

Systems Support reviews grid and programs IDX

Scheduler schedules appointments in IDX

Systems Support flips/reschedules appointments

Patients overload system or Providers receive limited support

Limited pool

Restrictive templates

Limited responses

Clinic de-prioritized

Precedes availability

Patient Waiting

Last minute requirements

Clinic de-prioritized

Failure Points

Nurse Midwife Lead develops CNM grid (providers and schedule)

Multiple Grid routes

• Highly complex process subject to failure

• Decentralized Provider scheduling leading to sub-optimization

38

Measure: Scheduling Process Map

Process

People

MachineEnvironment

MetricsMaterials

Appointment Availability & Continuity

Individual Provider approaches to mitigating bumps

Late clinic cancellations

Minimal scheduling protocols (acuity)

No protected time for acute appointments

Limited guidelines on Provider availability

Unclear Provider selection by appointment type

Bumps placed as overloads

Multiple routes for Provider scheduling

Multiple scheduling algorithms

Half-day clinic schedules at multiple sites

Individualized Provider profiles

Decentralization of scheduling function

Multiple locations of service

Multiple service types (L&D, call, clinic)

Room availability

Staff availability

Provider Availability

High demand on Providers

Multiple Mission requirements Clinic de-prioritization

Patient description of complaint

Scheduler identification of acuity

No penalty for poor service

Complex Provider scheduling process requires multiple rework cycles and last minute coordination

Provider controls own availability

Shortage of Providers to Demand

Cascading failure: Clinic cancellations lead to bumps lead to overloads lead to lengthy waits and reschedules

Varying process routes result in confusion and Provider dissatisfaction 39

Analyze: Appointment Availability and Continuity Causes

0

500

1000

1500

2000

2500

3000

1Aug06 2Sep06 3Oct06 4Nov06 5Dec06 6Jan07 7Feb07 8Mar07

1HMT420/440/4502OB17Davis3IVF4F-2Back5Total

Sum of Arrived

Month

Scheduling Location

0

500

1000

1500

2000

2500

3000



Sum of Arrived

Month

Scheduling Location

0.7

0.75

0.8

0.85

0.9

0.95



Sum of Arrival %

Month

Scheduling Location

0.7

0.75

0.8

0.85

0.9

0.95



Sum of Arrival %

Month

Scheduling Location

Analyze: Arrival* Analysis

• 1800 – 2500 arrivals per month

• Relatively stable arrivals

• Some potential increases (among GYN practices)

• 70 – 83% arrivals/scheduled

• Bumps: 3 – 9%

• Same Day Cancels: 6 – 11%

• No-Shows: 6 – 7%

Arrivals

Arrivals/Scheduled

* - Arrival = Scheduled – (Bumps + Same Day Cancels + No Shows)

Data: Clinical Monthly Report (8/06 – 3/07)

40

Analyze: Provider Schedule

• 5 overloaded clinic spaces (<2 Rooms/ Provider)

• Multiple open spaces:• Primarily Wednesday

mornings (Grand Rounds)

• Scattered throughout rest of week (except Tuesdays)

• Utilization efficiency:• 420 available slots

• 254 slots utilized

• 60% slot efficiency*

• 3.47 rooms/Provider**

April

Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon420 Hoffman Hoffman Sayer Sayer Hoffman Hoffman Hoffman Hoffman Kelly440 Keefe Kay Hoyte Hoyte Parsons, A. Hochberg Hoyte Hoyte

Parsons, A. Parsons, A. Keefe Parsons, A.Hoyte

450 Connery Wyckoff Lynch Cox Cox Lynch Lynch BrumleyBrumley Davis Wyckoff

17 Davis OB McCord Connery Cox Lynch Davis Brumley Davis McCarthy BrumleyKelly Brumley Wyckoff Brumley McCord Davis KellyWyckoff McCord Brumley Wyckoff

McCord17 Davis HR Quintero Quintero Kontopoulos Quintero Kontopoulos Parsons, M. Kontopoulos

Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon420 Hoffman Hoffman Sayer Sayer Hoffman Hoffman Hoffman Hoffman440 Hochberg Kay Hoyte Hoyte Kay Parsons, A. Hochberg Parsons, A.

Keefe Parsons, A. Parsons, A. Kay Keefe450 Brumley Davis McCarthy Cox Connery

Spellacy Wyckoff Brumley

17 Davis OB Connery Connery Brumley Spellacy Davis Brumley Davis Kelly ConneryWyckoff Wyckoff Brumley Davis BrumleyKelly Brumley

Kelly17 Davis HR Quintero Quintero Kontopoulos Kontopoulos Kontopoulos Parsons, M.

Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon420 Hoffman Hoffman Sayer Sayer Hoffman Hoffman Hoffman Hoffman Kelly440 Hochberg Hochberg Hoyte Hoyte Parsons, A. Hochberg Hoyte Hoyte

Keefe Kay Parsons, A. Parsons, A. Kay Hoyte Parsons, A.Keefe

450 Brumley Lynch Cox Lynch Lynch Tebes TebesDavis McCarthy Wyckoff

Spellacy Brumley17 Davis OB Wyckoff Brumley Cox Lynch Tebes Brumley Davis McCarthy Brumley

Kelly Brumley Brumley Kelly Davis Kelly WyckoffSpellacy

17 Davis HR Quintero Quintero Kontopoulos Parsons, M. Kontopoulos Parsons, M. Parsons, M.

Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon420 Hoffman Hoffman Sayer Sayer Hoffman Hoffman Hoffman Hoffman McCord440 Keefe Kay Hoyte Hoyte Parsons, A. Hochberg Hoyte Hoyte

Parsons, A. Parsons, A. Kay Hoyte Parsons, A.Keefe

450 McCarthy Connery Connery Cox Hart Connery Lynch Tebes TebesBrumley McCarthy Davis Spellacy McCarthy Lynch Brumley

17 Davis OB Connery Brumley Cox Spellacy Tebes Brumley Connery Connery BrumleyMcCord Kelly Brumley Brumley Brumley Davis Davis Kelly McCordKelly McCord Connery Davis


Morning Afternoon420 Hoffman Hoffman440 Hochberg Hochberg

Keefe Kay450 McCarthy McCarthy

Wyckoff TebesBrumley

17 Davis OB Tebes BrumleyMcCord McCordKelly

17 Davis HR Parsons, M.

30Monday

Friday23 24 25 26 27

Monday Tuesday Wednesday Thursday

Friday16 17 18 19 20


Friday9 10 11 12 13


Friday2 3 4 5 6

Monday Tuesday Wednesday ThursdayApril

Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon420 Hoffman Hoffman Sayer Sayer Hoffman Hoffman Hoffman Hoffman Kelly440 Keefe Kay Hoyte Hoyte Parsons, A. Hochberg Hoyte Hoyte

Parsons, A. Parsons, A. Keefe Parsons, A.Hoyte

450 Connery Wyckoff Lynch Cox Cox Lynch Lynch BrumleyBrumley Davis Wyckoff

17 Davis OB McCord Connery Cox Lynch Davis Brumley Davis McCarthy BrumleyKelly Brumley Wyckoff Brumley McCord Davis KellyWyckoff McCord Brumley Wyckoff

McCord17 Davis HR Quintero Quintero Kontopoulos Quintero Kontopoulos Parsons, M. Kontopoulos

Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon420 Hoffman Hoffman Sayer Sayer Hoffman Hoffman Hoffman Hoffman440 Hochberg Kay Hoyte Hoyte Kay Parsons, A. Hochberg Parsons, A.

Keefe Parsons, A. Parsons, A. Kay Keefe450 Brumley Davis McCarthy Cox Connery

Spellacy Wyckoff Brumley

17 Davis OB Connery Connery Brumley Spellacy Davis Brumley Davis Kelly ConneryWyckoff Wyckoff Brumley Davis BrumleyKelly Brumley

Kelly17 Davis HR Quintero Quintero Kontopoulos Kontopoulos Kontopoulos Parsons, M.

Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon420 Hoffman Hoffman Sayer Sayer Hoffman Hoffman Hoffman Hoffman Kelly440 Hochberg Hochberg Hoyte Hoyte Parsons, A. Hochberg Hoyte Hoyte

Keefe Kay Parsons, A. Parsons, A. Kay Hoyte Parsons, A.Keefe

450 Brumley Lynch Cox Lynch Lynch Tebes TebesDavis McCarthy Wyckoff

Spellacy Brumley17 Davis OB Wyckoff Brumley Cox Lynch Tebes Brumley Davis McCarthy Brumley

Kelly Brumley Brumley Kelly Davis Kelly WyckoffSpellacy


Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon Morning Afternoon420 Hoffman Hoffman Sayer Sayer Hoffman Hoffman Hoffman Hoffman McCord440 Keefe Kay Hoyte Hoyte Parsons, A. Hochberg Hoyte Hoyte

Parsons, A. Parsons, A. Kay Hoyte Parsons, A.Keefe

450 McCarthy Connery Connery Cox Hart Connery Lynch Tebes TebesBrumley McCarthy Davis Spellacy McCarthy Lynch Brumley

17 Davis OB Connery Brumley Cox Spellacy Tebes Brumley Connery Connery BrumleyMcCord Kelly Brumley Brumley Brumley Davis Davis Kelly McCordKelly McCord Connery Davis


Morning Afternoon420 Hoffman Hoffman440 Hochberg Hochberg

Keefe Kay450 McCarthy McCarthy

Wyckoff TebesBrumley

17 Davis OB Tebes BrumleyMcCord McCordKelly

17 Davis HR Parsons, M.

30Monday

Friday23 24 25 26 27


Friday16 17 18 19 20


Friday9 10 11 12 13


Friday2 3 4 5 6


* - Efficiency based on slot equal to 2 rooms

** - Based on 21 room availability per half- day 41

Issues:

• Multiple routes for scheduling adjustment into Systems

• Potential sub-optimization within Division

• Allowable last minute changes

• Last minute publication

• Loose controls on clinic adjustment process

Resolution:

• Single leader (and conduit for information to Scheduling Support)

• Schedule for 3 month period

• Publish two months ahead of schedule start

• Tighten process for clinic adjustments including space and patient considerations

42

Improve: Issues and Resolution

43

Improve: Simplify Appointment Types

• Streamlined appointment types (with elimination of redundant types)

• Set reasonable time periods for appointment length

Type Appointment DurationLOB Low Risk OB 15MOB Medium Risk OB 15HOB High Risk OB 20NOC New OB Corporation 30NOP New OB Practice 30PPE Post Partum Evaluation 15EPV Established Patient Visit 20AEP Annual Established Patient 20POV Post Operative Visit 20NPC New Patient Corporation 30NPP New Patient Practice 30EEP Established Procedure 30

43

44

Improve: Standardize Appointment Templates

• Set standard availability/mix of appointment types and order of appointments

• Leveraged system flexibility to fill appointments

Template: OBGYN Clinic Template: OBGYN ClinicAM session location: SC4 PM session location: SC4Session end time: 1200N Session end time: 500P

8:00 - 9:00 1:00 - 2:00LOB 4 MOB 4 HOB 3 LOB 4 MOB 4 HOB 3EPV 3 AEP 3 POV 3 EPV 3 AEP 3 POV 3

PPE 19:00 - 9:30NOC 1 NOP 1 Switch to any at 7 days out 2:00 - 2:30

NOC 1 NOP 1 Switch to any at 7 days out9:30 - 10:00NPC 1 NPP 1 Switch to any at 3 days out 2:30 - 3:00

NPC 1 NPP 1 Switch to any at 3 days out10:00 - 10:40EPV 2 AEP 2 POV 2 Switch to any at 3 days out 3:00 - 3:40

EPV 2 AEP 2 POV 2 Switch to any at 3 days out10:40 - 11:30LOB 3 MOB 3 HOB 2 Switch to any at 3 days out 3:40 - 4:10PPE 1 NPC 1 NPP 1 Switch to any at 3 days out

11:30 - 12:00 4:10 - 4:30EEP 1 Switch to any at 3 days out EPV 1 AEP 1 POV 1 Switch to any at 3 days out

44

45

Improve: Level-load Provider Schedules

SundayDivision/Group Provider Week HS AM PM HS AM PM HS AM PM HS AM PM HS AM PM HS

GEN Bruder 1 Gen Gen Cover Cover TGH CALL1 Cover CoverGEN Bruder. 2 Gen. Gen. Cover. Cover. PC. PC. CMS. CMS. Cover. Cover.GEN Burgess 1 OBG OBG PC-1/Cover-3,5 NH-1/Cover-3,5 TGH CALL2 PC PC/WH-1 Cover JE-3/Cover-1,5 L&D2 L&D2GEN Burgess. 2 Cover. Cover. Cover. Cover. SS-2/UA-4. Cover-2/Mors OR-4. Ke-2/Mors OR-4. OBG. OBG.GEN Connery 1 L&D2 L&D2 OB OB GYN TGH CALL2 PC PC OBG OBGGEN Connery. 2 L&D2. L&D2. OB. OB. GYN. TGH CALL2. PC. PC. TGH OR. TGH OR.GEN Cox 1 GYN-1,5/TGH OR-3 GYN-1,5/TGH OR-3 USF USF OB USF USF Mors OR-1,5/USF-3 Mors OR-1,5/USF-3GEN Cox. 2 USF. USF. USF. USF. USF. L&D2. L&D2. TGH CALL2. PC. PC.GEN Dileo 1 Cover Cover GYN GYN GYN TGH CALL1 PC PC GYN GYNGEN Dileo. 2 Cover. Cover. GYN. GYN. GYN. GYN. GYN. TGH OR. TGH OR.GEN Glazerman 1 MOR MOR MOR MOR MOR MORGEN Glazerman. 2 MOR. MOR. MOR. MOR. MOR. MOR.GEN Holmstrom 1 ACAD Lee Davis TGH CALL1 PC/Cover PC/Cover ACAD GYN TGH OR-1,5/Mors OR-3 TGH OR-1,5/Mors OR-3 GYN GYNGEN Holmstrom. 2 ACAD. Lee Davis. Cover. Cover. ACAD. GYN. TGH OR-1,5/Mors OR-3 TGH OR-1,5/Mors OR-3 GYN. GYN.GEN Klasko 1 OBGGEN Klasko. 2 TGH CALL1-4.GEN Kohl 1 GEN GEN GEN GENGEN Kohl. 2 GEN. GEN. GEN. GEN.GEN Lynch 1 TGH OR TGH OR GYN OB GYN GYN TGH CALL2 PC PCGEN Lynch. 2 TGH OR. TGH OR. GYN. OB. GYN. GYN. L&D2. L&D2.GEN Malina 1 OBG OBG TGH CALL2 PC/Cover PC/Cover L&D2 L&D2 TGH OR-1,5/Mors OR-3 TGH OR-1,5/Mors OR-3 USF USFGEN Malina. 2 OBG. OBG. OB. OBG. Cover. Cover. USF. USF. USF. USF.GEN Palmer 1 Research Research USF USF USF USFGEN Palmer. 2 Research. Research. Cover. Cover. USF. USF.GEN Patel 1GEN Patel. 2GEN Rao 1 Cover Cover L&D2 L&D2 OB OB OB OB OBGEN Rao. 2 OB. OB. TGH CALL2. PC. PC. OB. OB. OB. OB. OB.GEN Smith 1 GYN GYN OBG OBG TGH OR TGH OR OBG OBGGEN Smith. 2 GYN. GYN. L&D2. L&D2. TGH CALL2. PC. PC. OBG. OBG. Cover. Cover.GEN Spellacy 1 ACAD Lee Davis Jail OBG Gen TGH OR TGH OR Gen HRGEN Spellacy. 2 ACAD. Lee Davis. OBG. Gen. TGH OR. TGH OR. Gen HR.GEN Wyckoff 1 GYN GYN TGH OR TGH OR Cover Cover L&D2 L&D2 OBG GYNGEN Wyckoff. 2 GYN. GYN. TGH CALL1-2. PC. PC. GYN. GYN. OBG. GYN.CNM Brumley 1 GYN OB GYN OB CNM L&D CNM L&D Gen CNM Gen CNM OB OBCNM Brumley. 2 GYN. OB. GYN. OB. CNM L&D. CNM L&D. Gen CNM. Gen CNM. OB. OB.CNM Davis 1 USF USF GYN OB OB OB CNM L&D CNM L&D USF USFCNM Davis. 2 USF. USF. GYN. OB. OB. OB. CNM L&D. CNM L&D. USF. USF.CNM Jevitt 1 USF USFCNM Jevitt. 2 USF. USF.CNM Kelly 1 CNM L&D CNM L&D Gen CNM Gen CNM CNM L&D OBCNM Kelly. 2 CNM L&D. CNM L&D. Gen CNM. Gen CNM. CNM L&D. OB.CNM McCord 1 OB OB Gen CNM Gen CNM OB OB OB OB CNM L&D CNM L&DCNM McCord. 2 OB. OB. Gen CNM. Gen CNM. OB. OB. OB. OB. CNM L&D. CNM L&D.

Clinic Load Analysis: Maximum Week AM PM HS AM PM HS AM PM HS AM PM HS AM PM HSSTC Generalist/CNM 8 1 7 8 8 8 2 9 4 5 8 8STC Generalist/CNM. 8 2 7 8 7 8 2 8 7 8 6 6

USF 4 1 3 2 3 3 1 2 3 3 4 3USF. 4 2 3 3 3 3 0 2 2 2 5 4

Outside Load Analysis:Required Week AM PM HS AM PM HS AM PM HS AM PM HS AM PM HSTGH OR 2 1 2 2 4 4 1 1 2 2 2 2TGH OR. 2 2 3 3 3 3 1 1 1 1 4 4

TGH CALL1 1 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 0TGH CALL1. 1 2 0 0 0 0 0 1 0 0 1 0 0 1 0 0 0

L&D2 1 1 1 1 1 1 1 1 1 1 1 1L&D2. 1 2 1 1 1 1 0 0 1 1 1 1

TGH CALL2 1 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 0TGH CALL2. 1 2 0 0 1 0 0 1 0 0 1 0 0 1 0 0 0

Wednesday Thursday

Tuesday

Friday

FridayWednesday Thursday

Monday

Monday

Monday

Tuesday

FridayWednesdayTuesday Thursday

• Includes all Providers’ recurrent weekly schedules• Sums load in each clinical space and outside service

demands (except L&D and non-weekly requirements)• Color-codes availability, overfills, and shortfalls

Provider Names

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Improve: Visually Manage Provider Schedules

• Published greater than 30 days before 1st day of month• Clearly identifies assignments for each Provider using

standard naming conventions

Month: April DRAFT1st of month is: WednesdayNo. days/month: 30

Monday -1 Tuesday 0 Wednesday 1 Thursday 2 Friday 3Provider AM PM AM PM AM PM AM PM AM PM

Bruder Gen Gen Cover Cover 0 0 L&D1 L&D1 L&D1 L&D1Burgess OBG OBG PC-1/Cover-3,5 NH-1/Cover-3,5 PC PC/WH-1 obg kelton vac vacConnery L&D2 L&D2 OB OB 0 GYN PC PC OBG OBG

Cox GYN-1,5/TGH OR-3GYN-1,5/TGH OR-3 USF USF 0 OB USF USF Mors OR-1,5/USF-3Mors OR-1,5/USF-3Dileo Cover Cover GYN GYN 0 GYN GYN GYN GYN GYN

Glazerman MOR MOR 0 0 0 MOR 0 MOR MOR MORHolmstrom ACAD Lee Davis PC/Cover PC/Cover ACAD GYN TGH OR-1,5/Mors OR-3TGH OR-1,5/Mors OR-3 GYN GYN

Klasko 0 0 OBG 0 0 0 0 0 0 0Kohl 0 0 0 0 0 0 GEN GEN GEN GEN

Lynch TGH OR TGH OR GYN OB pc pc GYN GYN PC PCMalina OBG OBG PC/Cover PC/Cover L&D2 L&D2 TGH OR-1,5/Mors OR-3TGH OR-1,5/Mors OR-3 USF USFPalmer 0 0 Research Research USF USF USF USF 0 0Patel 0 0 0 0 0 0 0 0 0 0Rao Cover Cover L&D2 L&D2 L&D1 L&D1 L&D2 L&D2 L&D2 L&D2

Smith GYN GYN OBG OBG 0 0 TGH OR TGH OR OBG OBGSpellacy ACAD Lee Davis Jail OBG 0 Gen TGH OR TGH OR Gen HR 0Wyckoff GYN GYN TGH OR TGH OR Cover Cover pc pc OBG GYN

Provider Names

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Control: Daily Arrivals Baseline and Improved States*

Stage 1 (HMT/17D):

• Avg: 112.2

• Std Dev: 22.7

Stage 2 (STC):

• Avg: 111.1

• Std Dev: 27.6

Stage 3 (Schedule process):

• Avg: 127.5

• Std Dev: 14.5

* - Weekday arrivals, not including Wednesdays (7/2/07 – 10/9/07); n = 57

What’s changed?

• Assignment matrix maximizing space utilization

• New schedule process

• Nurse Manager filling open slots

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15% increased volume and

reduced variation

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Control: Benefit Calculation

• Average RVU’s per generic GYN appointment = 2.97*• Increase in appointments = 15.3 appointments per day

(Base line: 112.2 appt./day; Post-improvement: 127.5 appt./day)

• At $38/RVU x 2.97 RVU’s/appointment x 15.3 appointments/day x 200 work days per year (excludes Wednesdays) = $345K annual benefit

• Does not include added cost to service or downstream revenue (from procedures)

* - GYN arrivals at HMT 450 (7/3/06 – 6/29/07); n = 4482 48

Exercise: Broader Application

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• Optimize physician group office schedule

• Improve assignment of OR block times

• Integrate multiple scheduling processes

Using these approaches, what broader potential applications exist within healthcare?

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• Purpose: To develop a brand for USF Women’s Health and put it into operation

• Relevance: Taking control of and improving the brand will increase and improve the image of USF Women’s Health within the community leading to increased support, service delivery, and revenues.

Purpose and Relevance: USF Women’s Health Branding

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Identify audience

Develop audience interests

Specify intended actions

Develop message

• Who do we need to reach?

Identify media

Specify routing

• What is important to them?

• What do they want that is difficult to get?

• What do we want them to do?

• What is it they need to hear?

• What will lead them to act?

• What is the message format?

• Where do we place our message?

• Patients • “Give me good care.”

• “Don’t waste my time.”

• “Spend time with me and listen to me.”

• Schedule for own and families’ care

• Broaden use of services

• Tell others about positive experiences

• Wide-range of services

• Top of the line care-givers

• Service-oriented care

• Brochure • Placement in USF Health clinics

• Placement in partner locations

Other customers:

• Donors

• Referring Physicians

• Students

Other media:

• Posters

• Mailers

• Calendar of events

Branding Design Process

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Design: Promotional Materials

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June 2009:

• Issue: Long lines at front desk

• Resolution: Additional check-in station and person, system for back-up support

Improve: Operational Actions

October 2009:• Issue: Poor access• Resolution: Increased support for

clinical messaging, adjusted lunch breaks, launched MS Office Communicator, instituted nurse training of schedulers

Count 6 4 3 3 5Percent 28.6 19.0 14.3 14.3 23.8Cum % 28.6 47.6 61.9 76.2 100.0

Complaint Group

Other

Long

Line

s at F

ront D

esk

Chec

k-ou

t Proce

ss at F

ront Des

k

Long

Wait

Tim

e to See

Doc

tor

Poor C

ommun

icatio

n

20

15

10

5

0

100

80

60

40

20

0

Count

Perc

ent

Pareto Chart of Complaint Group

Count 1 1 12 2 2 1 1 1 1 1Percent 7.1 7.1 7.114.314.314.3 7.1 7.1 7.1 7.1 7.1Cum % 85.792.9100.014.328.642.950.057.164.371.478.6

Complaint Category

14

12

10

8

6

4

2

0

100

80

60

40

20

0

Count

Perc

ent

Pareto Chart of Complaint Category

Patient Comment

Cards

Patient Comment

Cards

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Improve: Service LineDevelopment

• Brings together:• Maternal Fetal Medicine• Neonatology• Pediatric Surgery

• Seamless service delivery through Nurse Coordinator

• Multi-disciplinary case evaluation

• Supported through regular outreach and communication

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Improve: Design Principles and Realization

Design Principle

• Seamless movement among services

• Delivery of all services to target specifications reflective of needs of customers (referring physicians, patients)

• Clear communication among various services

• One stop shopping

Realization

• Patient navigator supports ease of movement; No reintroduction to central scheduling after entry

• Established and adhered to service standards including cycle times and quality

• Operational mechanism of weekly multi-disciplinary meeting; Care plan development and management; PRN emergency meeting

• Bundled service delivery; Completed follow-on service coordination and education during single visit; “Care to Patient” service model

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Improve: Appointment Tiers

First Tier• Ultrasound• MFM• Neonatology• Tour of NICU

Second Tier• Pediatric

Surgery• Adult Cardiology• Pediatric

Cardiology• Additional Adult

and Pediatric sub-specialties

Third Tier• Anesthesia

• Second tier appointment types may be included in the first tier appointment based upon Patient Navigator determination

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Scheduling forwards request to Patient Navigator

Scheduling forwards call to Patient Navigator

Physician/ CNM refers Patient to

MFM

Physician/ CNM office calls Patient Navigator

Patient Navigator receives request and initiates/ updates medical record

Patient Navigator contacts patient

Patient calls Scheduling

requesting an MFM appt.

Patient requests an

MFM appt. via USFH

website

Patient Navigator requests/ receives scans and test results

Patient Navigator completes information sheet and schedules appointment(s)1

week2 weeks

Patient arrives for appointment(s)

USFH Physician/ CNM refers Patient to

MFM

USFH Physician/ CNM completes referral form (“pinkie”)

Genesis Physician/ CNM refers Patient to MFM

Genesis Nurse coordinates MFM appointment through Patient Navigator

Improve: Patient Access Process Map

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• Establish organizational brand (promotional and operational aspects)

• Launch service lines (women’s health center, heart health) based on leveraging and coordinating multiple practices


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• Purpose: To identify and address customer service issues within USF Women’s Health through a staff and physician driven team

• Relevance: Staff and physicians, through their routine interaction with patients, are well positioned to identify and resolve service issues to increase customer satisfaction.

Purpose and Relevance: Launch STEP* Team

* - Strive to Excel Program

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Measure: Employee Recognition Program

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• Poor communication (28%)• Long Wait Time to See Doctor (19%)• Front Desk Check-out Process and Lines (28%)

Analyze: Patient Complaints*

* - STEP Program Patient Comment Cards collected 11/08 (n = 21)

Count 6 4 3 3 5Percent 28.6 19.0 14.3 14.3 23.8Cum % 28.6 47.6 61.9 76.2 100.0

Complaint Group

Other

Long

Line

s at F

ront D

esk

Chec

k-ou

t Proce

ss at F

ront Des

k

Long

Wait

Tim

e to See

Doc

tor

Poor C

ommun

icatio

n

20

15

10

5

0

100

80

60

40

20

0

Count

Perc

ent

Pareto Chart of Complaint Group

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Count 8 1 1Percent 80.0 10.0 10.0Cum % 80.0 90.0 100.0

Compliment Group

Overall n

ice e

xper

ience

Appo

intmen

t on-

time

Exce

llent

Pat

ient

service

- Be

havio

r

10

8

6

4

2

0

100

80

60

40

20

0

Count

Perc

ent

Pareto Chart of Compliment Group

Top issues:• Excellent Patient service -

Behavior (80%)

Analyze: Patient Compliments*

* - STEP Program Patient Comment Cards collected 11/08 (n = 10)

Secondary issues:• Appointment on-

time, Overall nice experience (20%) 62

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Improve: Error Proof Scheduling Location

Check screen added to confirm alternative location

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Improve: Clinic Status Updates

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• Launch employee recognition program

• Set-up service metrics with linked improvement activities

• Initiate service standards


Impact

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Outpatient Volume

• Increased outpatient visits ~150% over 4 years (’05-’09) with associated revenue*

• Improved schedule regularity and provider satisfaction

• Reduced bumps with associated patient frustration and rework

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

FY2000

FY2001

FY2002

FY2003

FY2004

FY2005

FY2006

FY2007

FY2008

FY2009

FY2010(proj)

0

5

10

15

20

25

30

Visits

South Providers

* - Increase in South Providers by 42% (from 19 to 27)67

Other Metrics

• Went from losing $1M per year to making $1M per year

• Easier discussions regarding salary increases, bonuses, and purchases

• Increased patient satisfaction

• Being listened to

• Responding to their issues

• Increased appointment availability

• Better scheduling processes

• Reduced appointment bumps

• Standard brand appearance and improved recognition

• Improved relationships with affiliated hospital and other departments (pediatrics, surgery)

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Thank you for your time.

Questions?

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Creating a Culture of Excellence at USF Women's

Education

Transcript of Creating a Culture of Excellence at USF Women's