By Jim Chrisinger, Continuous Improvement Director
King County’s ten public health centers and primary care clinic at Navos have been challenged by a combination of budget pressures, demand for their services, and a new business environment created by health care reform. The status quo was not sustainable.
I talked with three Community Health Services (CHS) leaders downtown and visited the Eastgate Public Health Center in Bellevue to learn how Lean is helping CHS respond to these challenges. (This month’s Employee Spotlight below features Eastgate’s Area Manager, Fidelis Nkeze.) CHS’s “productivity initiative” is yielding results and changing workplace culture.
What problem are you trying to solve?
In mid-2013, we could see that the number of clinic visits and our revenues were lower than expected. We drilled into the data at two of our sites and used the Lean A3 problem-solving method to learn more about why our performance was not what we wanted, and to generate some mitigation strategies. (Part of A3 problem-solving is root cause analysis. Click here to see a “fishbone diagram” that CHS used to find out why there was a decrease in Public Health clients receiving family planning services.)
Michelle Pennylegion, Public Health Center Program Quality Manager, and Sarah Klevit Hopkins, Triple Aim Manager
We realized that we needed to maximize our capacity to meet the demand for services. We needed to better understand the relationships between client demand, our budget, and opportunities for more efficient service delivery. We have been building budgets on what we did, not what we could do. And our systems weren’t helping us learn. We needed to know what it’s possible for us to do.
What are you doing to improve?
We started by becoming curious and with a desire to learn. That was our primary motivation. We didn’t want to just dictate numbers in the form of targets. We wanted to engage our folks around data so we could both measure success and identify barriers.
We began collecting data, daily, on the client visits at every public health center for each of the four programs: family health, family planning, dental, and Maternity Support Services/Infant Case Management (MSS/ICM). We began to look at the number of visits per week and provider productivity, usually by the number of visits per clinical contact hour. Now that we could see the current levels of visits and productivity, we could project the levels it would take to reach our revenue targets. The gaps were big. We could see that fundamental change was needed.
Because of the budget situation, we needed a sense of urgency so we borrowed the Incident Command Structure (ICS) that we use for crises such as large disease outbreaks to develop rapid cycles for improvement ideas and testing.
Our budget challenge also uncovered inconsistencies and barriers to health care enrollment at the clinics. We started to work on this problem too, in the Incident Command Structure. Then we realized that we were trying to do too much. So we decided to hold a Lean event, which the team in this picture conducted recently at Northshore Public Health Center. As a result, we will increase enrollment of our uninsured clients, which will enable CHS to serve more people and gain more revenue.
Putting the data out there so everyone could see got everyone talking. At first, people pushed back: the data’s wrong, it doesn’t fairly show what’s happening at our site, it doesn’t take staffing into account, etc. Many times they were right. We were learning and these conversations were good. We made a lot of changes as we learned.
We also had to get beyond our initial instinct to praise the “green numbers” (showing targets met) and be concerned about the “red numbers” (showing targets not met). It’s about learning and improvement, not whether the numbers are green or red. Staff at the sites understood this better than we did at first. We all got better. What does the data tell us? How are staff engaged? What can we do with what we’ve learned? What do you need from us?
The data pointed us toward best practices. Take scheduling for example. Clinic visit “no shows” hurt productivity and we noticed that they tend to happen more often at certain times of the day. So some sites experimented with double booking appointments at those times. It worked, so the idea was spread to the other sites. We also found that more reminder calls to clients reduced the number of “no shows.” A bi-weekly call with all the sites facilitates this kind of sharing.
The data also showed us that primary care visits for kids take less time than for adults, because adults tend to have more complicated histories. Changing the schedules enabled us to do more pediatric visits. We’re also experimenting with later hours on some days.
The data conversations have also helped us break down the program silo walls at the clinics. “We have openings in dental today,” prompts inquiries about the clients coming in for other programs; some of them may also need a dental appointment. We’re also working on referrals from one program to another, with warm handoffs. We’re moving from focusing on a no-show rate to a fill rate. We’re now more focused on filling schedules to meet our clients’ needs, instead of wringing our hands about no shows.
Digging into the “why?” when our performance was falling short of target also led us to our hiring process, which was too slow. We can’t meet productivity targets if the positions needed to deliver service are not filled. So Tina Abbott and Dorene Hersh stepped up. Abbott is one of our HR professionals who has solid Lean experience and Hersh is our Chief of Nursing. They led a team that established hiring standards, standard work for hiring, time frames, and visuals so we could all see what was happening with hiring. Our lead time for hiring dropped from 92 days to 78 days, which helped us fill more than 50 vacancies during the ICS period.
We are also now holding productivity workshops, where staff from all the sites and Chinook get together to share, learn, and adopt common standards and the best practices that the system is now generating. The workshops are also helping us align around the targets, which will help us build budgets in the future.
T.J. Cosgrove, Interim Public Health Center Program Quality Manager: “We have a great team here. Doing this work has also helped us better define roles and define how we work together.”
Last October, we were at 88% of our system visit target. At the end of the first quarter of 2014, we are at 98% of a higher target. As a result, we are close to seeing the numbers of clients we need to see to meet our revenue goals. And we are increasing access for people receiving services.
Even more important, we’re working in a new way. All of us in the system are engaging with each other around data to improve. We feel like we’re doing a lot better in living the Lean principle of “respect for people.”
We want to get to the point where we have standards for productivity. Then we can completely align staffing, schedules, the budget, and ultimately what we can deliver to our clients.
We also want to get to quality standards and metrics. Ultimately, this is about achieving the Triple Aim: improved health outcomes, improved client experience, and lower per capita costs of providing services.