1

Our Lean Journey

Introduction to Lean and Kaizen in HIM

2

ObjectivesAt the end of the presentation participants will

be able to:

• Restate a brief overview of Lean

• Explain why Lean is selected as a

management and Improvement system

• Describe different improvement methods

3

Lean

Lean is about eliminating waste in all forms throughout the organization to create value for the customer. To do this employees need to become problem solvers and continually ask the question WHY. (Lean Pathways, 2011)

4

Lean Management System

Continuous Improvement-

Kaizen Elimination of Waste and Variation

Respect for People; Engages

Employees and Providers

Value for the

Patient;

Quality Care at

an Affordable Cost

5

8 WastesTypes of Waste Description Examples

1. Motion

• Unnecessary movement to gather necessary items

• Usually refers to movement of tools or staff

• Actions of people that do not add value to the patient

1. Hunting and gathering

2. Ergonomic concerns such as bending to get

supplies from a lower cabinet

2. Waiting

• Delay between the end of one process and the

beginning of the next process

• Waiting on materials or information

1. Patients waiting for treatment, physicians

waiting for test results, nurses waiting for

medications, nursing assistants waiting for

supplies

2. Computer down time

3. Conveyance

• Movement of anything in a process that does not add

value to the patient

• Usually refers to movement of materials or patients

• May be the result of a non-efficient layout

1. Moving patients for testing or treatment

2. Moving equipment to the patient room

4. Correction

• Defects require rework

• Rework occurs when work contains errors or is not

completed but still passed along

• An error (or mistake) refers to anything that does not

go as planned in the process and a “defect” is any error

that is passed along

1. Blood redrawn

2. Incomplete information

5. Processing • Non-value added steps in a process

1. Asking the patient for the same information

multiple times

2. Redundant charting

6. Overproduction• Making or ordering more than you need or too soon

• Doing more than needed to satisfy the patient’s needs

1. Ordering excessive tests

2. Admitting patient when no beds are available

7. Inventory

• Any work, material or supplies on hand in excess of

what is needed in the immediate future in relation to

order or delivery dates

1. Supplies in storage

2. Hoarding – creating a personal stockpile,

possibly closer to the point of service

8. Knowledge

• Wasted Human Potential is when the Input of creative

ideas and suggestions from all is not taken

• To achieve quality at reduced cost and to strive for

perfection continually, we need all of us.

1. People not included in improvement

activities

2. Working above or below license

6

Signature Business

7

Round 11. Post-it notes must stay together – Do Not

Separate!2. Must sign name legibly 3. Only one person at a time can sign their

name on each of the post-it notes. 4. Once all five post-it notes are signed, the

pack is passed to the next person.5. Time stops when the last person finishes

signing all five post-it notes (timekeeper does not sign).

8

• Do I have a problem?

• Do I know the Root Cause?

• Have I confirmed Cause and Effect?

• Have I confirmed the countermeasures?

Four-Step Problem Solving

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Step 1Do I have a problem?

What should be happening?

What is actually happening

GO AND SEE

Process Observation

Data Collection

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Step 2Do I know the Cause?

• Why?

• Why?

• Why?

• Why?

• Root Cause– Lack of a standard

– Lack of adherence to a standard

– Inadequate system

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Why?-ExampleWhy #1 Why did the waitress deliver a burger without cheese?

Because the cook didn’t put any cheese on the burger.

Why #2: Why did the cook not put cheese on the burger?

Because he ran out of cheese.

Why #3: Why did he run out of cheese?

Because the supplier did not bring enough cheese.

Why #4: Why did supplier not bring enough cheese?

Because we didn’t ask them to.

Why #5: Why didn’t we ask?

Because we didn’t know we were out of cheese.

Why#6: Why did we not know we were out of cheese?

Because we do not have a standard for when we are low on cheese to re-order.

(Pascal, D. (7/6/10). The Remedy: Bringing Lean Thinking Out of the Factory to Transform the Entire Organization. Wiley.)

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Step 3Have I confirmed cause and effect?

Form a hypothesis

If this (Process), then this (Outcome).

If you do this (Process metric)

Then you will get this (Outcome metric)

Try something Quick experimentationCreativity before dollars

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PLANPLAN

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Step 4Confirm Countermeasures Results from your experiment

How will you check? Who Will Check? When?

Week 1 Week 2 Week 3 Week 4

Experiement

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Quick and Easy Kaizen

• Purpose

• To engage everyone in solving problems and making daily improvements to our work lives and patient care.

• To relentlessly pursue the elimination of waste and the constant development of people.

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Employee

Idea /

Problem

Q&E Card_____

Not NowTeam + Leader

DispositionTeam + Leader

Assign +datesTeam + Leader

Action &

CountermeasuresTeam / Individuals

Process CheckLeaders SW

•Natural Team Visual

Display in workplace

•Daily/weekly pulsed

•4SPS basis

•“To Do” & “Doing”

steps are capacity

constrained

•Supported by LSW

Plan Do C&A

What is Quick & Easy Kaizen?

Q&E Card_____________

16

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Purpose of 5S

• Strategy for identifying and eliminating waste in the workplace.

• A way to organize what you need to do your work, where and when you need it and in the right quantities (not too much or too little).

• Way to apply the principles of waste elimination, just in time efficiency and standard work.

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19

20

21

Sort• 1. Sort out unnecessary items-keep items based on

frequency of use

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2. Organize for the reduction of waste

3. Keeping the workplace clean

Set in Order & Shine

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Standardize & Sustain• 4. Developing a consistently organized workplace

• 5. A system for ongoing support of the first 4 steps

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“Without

standards there

can be no

improvement”

- Taiichi Ohno

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Standard Work

• Consistent Processes=Desired Results• The current best way we know how to do

the work

Before Standard Work With Standard Work

• Standard work should focus on the value added activities and help eliminate the others

Non Value Added

Work

Non Value Added

but Necessary

Value Added Work

Non Value Added

Work

Non Value Added

but Necessary

Value Added Work

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Visual Management Triangle

We see

together

We act

together

We know

together

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Visual Management and the Sports Analogy

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Huddle

– Status of our areas and how we know

– Mechanism or process to make the biggest problems from the last 24 hours visible

– Prevent potential problems for the current day (or whatever cycle of work makes sense)

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How Does Kaizen Benefit SH HIM Department?

• 387 WQ 4sps

• 387 Process and Outcome Metric

• Q&E Fish Idea

• Savings from fish idea from metric tracker

• Overall HIM Department 2016 FY savings from Lean Activities

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387 WQ 4SPS 387 WQ HIM Department

Steps 1 – Do I have a problem? Concern Not meeting $3 million 387 WQ DNB target

What Should be Happening?

Meet the $3 million 387 WQ DNB target

What is Actually Happening?

The 387 WQ DNB is averaging $5 million

Measurable Gap $ 2 million gap

Impact Financial, Patient experience (billing process), Patient care

Step 2 – Do I know the root cause? Point of Cause Conversation between Debra and Gena-Identified 387 WQ DNB is above the $ 3million

target

Direct Cause Why not meeting $3 million target? - Increased volume of incomplete records in the 387 WQ

Whys? Why increased volume of incomplete records in 387 WQ? - Because 387 WQ not analyzed often

Why 387 WQ not analyzed often? - Because resource only dedicated for a couple days’ worth of analyzing per week for

the 387 WQ - Why resource dedicated for a couple days analyzing of the 387 WQ? - Because resources dedicated to other tasks

Why resources dedicated to other tasks? - Because other tasks prioritized

Why other tasks prioritized? - Because, tasks were behind on TAT

Root Cause Lack of standard

Step 3 – Have I confirmed cause and effect? Hypothesis If 387 WQ is analyzed daily, then will decrease the $2 million gap by 15% ($300,000) per

week

Experiment & Start Date

Someone from R.I will analyze 387 WQ on a daily basis

5-1-2016

Action Plan What/Where Who When

HIM Department

Record Integrity 5-1-2016

Step 4 – Have I confirmed countermeasure? What is your: Process Metric: Calendar- 387 WQ analyzed

M-F Outcome Metric: 387 WQ DNB Graphs

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387 WQ Process Metric

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4.14.4

4.8

3.6

4.8

6.1

5.25 5 5

5.8

6.7

4.3

3

6.1

5.2 5.25.5

5.2

4.8

5.6

5 5 55.3

44.2

3.9

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

0

1

2

3

4

5

6

7

8

$ M

illio

n

Axis Title

April 387 DNBAvg DNB for Month= $4.9 Million

Target =$3 Million

387 WQ Outcome Metric

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3.8

4.9

3.5 3.6

3.9

4.5 4.5

4.2 4.1 43.8 3.9 3.9 3.9 3.9

4.5

5 55.2 5.2 5.2

5

4.7

3.9

3.5

4 4 4 4 4

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

0

1

2

3

4

5

6

$ M

illio

ns

Date

May 387 DNBAvg for Month =$4.2 Million

Target=$3 Million

387 WQ Outcome Metric

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3.53.3

3.63.7 3.7

3.4

2.72.9

3.2

3.7

3.2 3.2

3.53.4

4.4

4.1

4.54.6 4.6

4.4

3.8 3.8

3.3

4.14.2 4.2

5

3.6

3.3

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

0

1

2

3

4

5

6

$ M

illio

n

June 387 DNB Avg DNB for Month = $3.75 Million

Target= $3 million

387 WQ Outcome Metric

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3.33.4 3.4 3.4

1.7

2.2

1.71.8 1.8 1.8

2

1.3

2

1.71.8

1.9

1.3

2

1.3

1.7

2.5

3.13

3.2

3.5

3.2

3.8

3.5

4.24.4 4.4

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

$ M

illio

n

July 387 WQ DNBAvg DNB for Month =$2.6 Million

$Million in DNB Target=$3Million

387 WQ Outcome Metric

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4.9

4.2

3.75

2.6

4.2

3 3 3 3 3

0

1

2

3

4

5

6

April May June July August

$M

ILL

ION

DATE

Monthly Avg of 387 WQ Target=$3Million

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Date:

Owner:

Problem:

WSBH:

WAH:

Impact:

Hypothesis:

Problem:

WSBH:

WAH:

Impact:

Hypothesis:

G

A

P

G

A

P

:

:

Metric Tracker Results:

Metric Tracker

Results:

Q&E Fish Idea• Q&E ideas can be quick and simple

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Date:

Owner:

Problem:

WSBH:

WAH:

Impact:

Hypothesis:

Problem:

WSBH:

WAH:

Impact:

Hypothesis:

G

A

P

G

A

P

:

:

Metric Tracker Results:

Metric Tracker

Results:

-Physicians are not utilizing paper charts that are pulled for surgery

-Replace pull list with floor requests. Only pull charts when physicians ask for them

-All charts are being pulled for surgery patients

-Over processing, time wasted pulling charts. Iron Mountain delivery

-If eliminate pull list and replace with floor request, then HIM staff can allot more time to other

tasks

- Metric Tracker Result: $5,200

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Date:

Owner:

Problem:

WSBH:

WAH:

Impact:

Hypothesis:

Problem:

WSBH:

WAH:

Impact:

Hypothesis:

G

A

P

G

A

P

:

:

Metric Tracker Results:

Metric Tracker

Results:

-Records submission to insurance companies by mail too slow, and costly

-Direct, secure upload (Regence and UHC, they have a portal that you can upload records via PDF-

Instant confirmation that records were received).

-Snail Mail, unconfirmed receipt of records

-Big savings in resources, confirmed receipt of records

-If direct uploads are used, then receipt of records are instant, allowing more time for rebuttals for

denials

-Metric Tracker Result: $ 1,690

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Date:

Owner:

Problem:

WSBH:

WAH:

Impact:

Hypothesis:

Problem:

WSBH:

WAH:

Impact:

Hypothesis:

G

A

P

G

A

P

:

:

Metric Tracker Results:

Metric Tracker

Results:

-Scanner too slow & produced poor quality images for legal requests

-Need new scanner to scan voluminous legal requests

-Rescanning documents/images to capture all information for legal requests

-New scanner will allow records be processed much quicker with quality-Eliminates re-work

-Metric Tracker Results: $3,900

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Savings

• Savings from fish idea from metric tracker

• $10,790 (Total of the 3 examples shown)

• Over all HIM Department 2016 FY savings from Lean Activities

• $1,293,975

• Hourly wage & time used before lean activity and after activity to capture true savings

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Lean in CodingEmphasis on engaging remote staff

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Quick and Easy Fishing Game

• Team Game, with individual points tracked

• We track both Q&Es, 4SPS and 5S with this game

• If an idea is not something we can do, we have a discussion with the person who submitted it to let them know why, we the move it to the parking lot

• The fishing derby is meant to track the progress. Often times we look at outcome metrics to track improvement. Once the idea is working, we complete it. If it is not showing improvement, we try another solution.

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Individual Scores

• By having individual scores posted, the employees feel motivated to complete ideas and help their team.

• Their team only gets to advance one space when an idea has been completed. This discourages excessive ideas being submitted.

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• Their direct report must approve the idea and when the project is completed, submit it into the metrics tracker which shows how many employees have led a Q&E or 4SPS and the departments total savings

• Our goal is to have 3 employees complete an idea per month which we are currently exceeding

Metrics Tracker

5

8

5

8

0

5

10

Jul Aug

2016

Num

ber

of

Activitie

s

Unique Staff Led & Total Activities

Total Activities Unique Staff LedData Source:

Kaizen Project

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Engaging Remote Staff

Weekly Huddles

• Standard Workflow on Discussion topics

• Have Go-To-Meeting and a webcam so that remote

staff can see all of our visibility boards.

• Ask for any kudos! (compliments to their team

members for going outside their normal job duties)

Monthly Check-Ins

• Standard Workflow on Discussion Topics

• Ask prompting questions to lead to a new Q&E or

4SPS

• Are you seeing any barriers to getting your job

done?

• What would you change to get to the ideal

state of your job?

• Process Metric posted in my office for accountability

• Quick and Easy Game to encourage Team involvement

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Standard Workflows in Coding to Identify Gaps

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Ancillary Standard Work

With so many different workflows in ancillary, it was essential for our team to write them out so that we could analyze them together to identify gaps.

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Waste Removed through Standard Work

Emailing for Missing Orders

• Multiple departments were asking our ancillary coders to email them weekly with accounts missing orders in addition to sending them to a WQ.

• We stopped this process which has saved our ancillary team 1.5 hours each week of unnecessary work.

Outpatient Rehab

• It was discovered that outpatient rehab had a especially complex workflow. We streamlined it immensely eliminating wasted communication between the coder and the department.

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Departmental A3 Financial Performance Focus: Discharge Dispositions

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Discharge Disposition Error Rate

Compliance Audit

• Traditionally, we tracked our disposition error rate through a quarterly audit of 30 inpatient accounts. Our accuracy rate showed 85-95%

How we identified the problem

• Other departments did some focused audits and found that our error rate for certain dispositions was higher than we thought, especially in outpatient.

• Come to find out, our outpatient coders were not focused on auditing the disposition every time. Some had no idea on how to find it.

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Discharge Disposition Improvement

Care Management Discussion• We found that the Disposition list had

multiple options for each claim value. We eliminated several options so that there were only a few claim values that had more than one patient value option.

• Routine discharge caused a lot of confusion for the team. They often chose SNF when a patient went to a RCF. So we wanted to list options.

• Example: Claim Value 03-Routine Discharge

• Patient Value 1-Routine-home independently, group home, home with relative

• Patient Value 2-RCF, ALF, Memory Care

Steps to improvement

• We updated the Discharge Disposition Policy

• Created a Discharge Disposition Standard workflow

• We hosted an educational session for the team and will every 6 months

• Conducted monthly targeted audits

• At the end of the year will conduct a high volume overall audit

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4SPS Part 1Steps 1 – Do I have a problem?

Concern Coders are not accurately capturing discharge dispositions on accounts with claim value 70, 21, and 65

What Should be

Happening?

Discharge disposition is accurate 95% of the time on accounts where coding is complete.

What is Actually

Happening?

Discharge disposition is not captured accurately 45% of the time on claim values 70, 21, and 65 by

coders.

Measurable Gap Approximately 50% based on current audits.

Impact Reimbursement is placed at risk, increased readmission rates, inaccurate reporting sent to CMS.

Step 2 – Do I know the root cause?

Point of Cause During initial 4SPS done by the coding team it was brought up that several dispositions are confusing

or repetitive.

Direct Cause Inaccurate discharge disposition entered by HIM.

Whys? 1. Why do we have a lack of understanding on how to apply discharge dispositions?

There are several dispositions in ADT which are not needed. The options are similar to others causing

confusion and incorrect options to be chosen

2. Why are there so many disposition options?

There is a claim value which is used by CMS and there are multiple patient values created by the hospital

to use for other needs.

3. Why are there multiple patient values?

Some are necessary to keep in ADT but some are not needed

4. Why haven’t the values which are not needed been removed?

The problem was not identified and corrected previously

Root Cause Inadequate System

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4SPS Part 2Step 3 – Have I confirmed cause and effect?

Hypothesis If we remove dispositions which are not needed and combine some which share the same CMS

value, we will decrease the amount of options allowing the coders to capture the correct disposition on those four claim values 95% of the time.

Experiment & Start Date We will have the ADT analysts remove the unnecessary options then see how many errors we find

next month. Focused audit will be on Claim Values 70, 21, and 65

Action Plan What/Where Who When

Analysis of Discharge Report Coding Supervisor Monthly

Step 4 – Have I confirmed countermeasure?

What is your: Process Metric: Monthly Analysis of Dispositions 70, 65, 21 Outcome Metric: Target 95%

Check and Adjust

Results of the

Experiment

Time: Process Metric Results: Outcome Metric Results:

Check 1 Date: 09/01/2016 76%

Check 2 Date: 10/01/2016

Check 3 Date: 11/01/2016

Was gap closed?YES NO

- Proceed with full implementation

- Quantify waste removed

- Enter results in to the Metrics Tracker

- Redefine the problem

- Examine the root cause

- Adjust the hypothesis

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Discharge Disposition ImprovementFocused Audit on Transfer to Another Facility

IP Psych, Law Enforcement, Transfer to Another Facility

0

5

10

15

20

25

30

35

Apr-16 May-16 Jun-16 Jul-16 Aug-16

Transfer to Another Facility

ED OP IP

0%

20%

40%

60%

80%

100%

July August September

Claim Values 65, 21, 70 Accuracy

ED OP IP Total:

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Questions?