Building the Chassis for Patient Centered Medical Home

Building the Chassis for Patient Centered Medical Home: Using Lean Leadership and Tools Peter Harper MD MPH, Wendy Nickerson, and C. J. Peek, Ph. D Dept of Family Medicine and Community Health / University of Minnesota Physicians 2012 STFM Annual Meeting April 28, 2012

Bottom line message 1. We have used Lean tools to build relationships that improve the “chassis” to carry Patient Centered Medical Home (PCMH). (IOM 2002 Crossing the quality chasm 2002: ”the chassis is broken”) 2. This allows us to make significant changes, build a trustworthy system, and maintain adaptive reserve in order to transform into a PCMH. 3. This new “chassis” and the process of building it will actually enhance resident education and build skills needed in the PCMH.

Outline 1. Introduction 2. Lean and Lean tools 3. Lean tools transform relationships--relationships have improved the “chassis” for care. 4. Intentional education linked to these changes--new learning experiences and expectations Questions and discussion 3

The old chassis isn’t going to carry PCMH 4

Need a New Chassis • Lessons learned from Transfor. MED (Nutting et al 2009) – Epic whole-practice re-imagination and redesign. . . – A continuous, unrelenting process of change. . . new scheduling, access, coordination arrangements. . . – Move from physician-centered to care shared by prepared office staff. . – Can result in staff burnout--change fatigue. . . – Necessitates leadership & staff development--building adaptive reserve • Need a new chassis capable of carrying PCMH and teaching the new skills needed by residents • Lean can help - Normalize, model, and teach process changes - Increase adaptive reserve - Create a trustworthy system (for patients, residents, & staff) 5

Lean • A philosophy and culture • Principles • Patient first • Make it visible • Remove the blame » Gentle on people, hard on processes • Make it better » Engaging the people who do the work » Focus on processes » Remove the “waste”

Lean • Focus on processes • Remove the waste (8 wastes) • Based on how patient experiences it • Standardization to sustain change • Tools are intuitive • Highly visible • Staff engagement • Taps the ideas and insights of the people working in the process • Sets a foundation for huge changes entailed by PCMH • To mobilize the group in making changes and • Maintaining the “adaptive reserve” to keep people from burning out in the process

Heard on the street…. • “It’s just process improvement with Japanese words thrown in” • “I heard about a group that did it and it didn’t work” • “It’s about cars, not people” • “It’s mechanistic, not relationship-oriented” • “It’s just about creating neat work areas” • “It’s all about saving money on supplies” • “It’s about cutting people and putting work on the backs of those who remain—not about making jobs more fulfilling”. • “Lean has nothing to do with resident education. ” 8

Lean Tools • • • 5 S Kanban Metric Board Huddle Board Standard Work Leadership 9

5 S Organized shared workspace 1. Sort 2. Set in order 3. Shine 4. Standardize 5. Sustain Before After “I don’t have anxiety attacks anymore when I go into the (supply) room. ” PCS staff 10

Kanban Inventory Management Supplies never run out, never overstocked Prevent outdated medications / supplies 11

Metric Boards Real-time, data-driven dashboard • Visual • Daily 12

Huddle Board Public display of problems, ideas, works in progress “I’ve learned to speak up at work…. and at home. ” Front desk staff 13

Standard Work Current best way of doing a job - Step by step - Builds consistency Sustained, reliable processes Standard work is the “block” that keeps the ball from rolling back 14

Lean Leadership & Communication Coaching and capacity-building 15

Lean Tools / New Chassis Lean Tools Trusting relationships Better chassis for care Better chassis for education • Lean tools help change relationships and behaviors • These new relationships and behaviors change the chassis (for both care and education) 16

Lean tools, relationships, improved chassis Lean Tools and Disciplines (A): 5 S: Organized shared workspace Kanban: Supplies never run out, never overstocked Trusting relationships Calmer, more trusting relationships with coworkers--shared workspace; less finger pointing Improved relationships with patients--less searching & muttering--more energy for care Better chassis for PCMH Engaged staff--eyes open, minds open, paying attention, sharing a philosophy Tools as outward expression of inner discipline Better chassis for education Uneventful clinics leave room for eventful education Builds trust in teams and systems Visual cues all around; more going on is “uneventful” Improved adaptive reserve: less tension & “splashing” (Nutting et al, 2009) 17

Engaged staff • • Eyes open Minds open Paying attention Participating in life of the clinic • Sharing a philosophy 18

Visual cues all around you Indicators and gauges • Simple, intuitive, visual • Eventful clinics • No crutches, No IUD • Exam room supplies • No blue pen • Uneventful clinics – increased efficiency and eventful education • Provide patient care in timely fashion • Bullet story 19

Inward discipline • “Wax on-Wax off” Manifestation of an internal discipline • Reflexive--I don’t have to decide whether to do it Karate Kid, 1984 20

Adaptive Reserve Nutting et al, 2009 • Less “my glass overflows with frustration” • More emotional energy for patients • More time for education 21

Better chassis for resident education • Uneventful clinics, eventful education – Care for patients - less running around – Visual cues - look competent – Inward discipline ticket to higher education activities – Resident exit interviews Cartoon • Builds trust in teams and systems – Adaptive skill needed in PCMH 22

Lean tools, relationships, improved chassis Lean Tools and Disciplines (B): Local, daily metrics: Real-time data dashboard Huddle board: Public display of problems, ideas, work in progress Trusting relationships Data-driven relationships: I can tell right away how I (and we) are doing Process focused, problem-solving relationships; everyone is a contributor--and can take pride Better chassis for HCH Data-driven change, not emotion-driven Better chassis for education Practice-based learning; “realtime EBM” at “point-of-service” Staff acting on their Systems-based practice; group own as problem solvers problem solving on publicly posted issues Hard on process, gentle on people —for good of all What matters to patients actually counts 23

Data Driven Change– Not Emotion-Driven • Check-in desk – New hire vs. cross training • Interpreter change – Familiar vs more available 24

Gentle on people, hard on process Forms process Cartoon Missing kanban cards 2 nd BP check 25

Staff solving problems (that matter to patients) • Phone room break coverage 26

Better chassis for resident education • Teaching “practice-based learning” • Cartoon – Real-time EBM – Point-of-service learning • Teaching “systems-based practice” 27

Lean tools, relationships, improved chassis Lean Tools and Disciplines (C): Standard work: The current best way to do something Lean leadership & communication: Coaching and capacity-building Trusting relationships Better chassis for HCH Accountability: can More accountability--individual tell if doing job well System trustworthiness: get help, not hide Better chassis for education Teaches standard teamwork and shared Sustained change--less backsliding Assistance & mentoring Deliberate, “designed in” communication & coaching Conscious balance of “topdown” / “bottomup Alignment - less scatter Teaches standard clinical work Models standard work of teaching & precepting Adaptive reserve--less change fatigue & initiative overload 28

Accountability / Sustained change • Standard work is shared “process space” • Know individual and group is doing job well • Sustained change 29

Designed-in Communication and Coaching • Individual coaching, not exhortation • Face-to-face – not mass emails • Based on data and standard work 30

Better chassis for resident education • Teaches standard teamwork – – – Physician distinct role Standardized teams/systems basis for customized warranted variation Professionalism • Teaches standard clinical work – – Consistent messages/patterns Decreased unwarranted variation • Models standard work of teaching and precepting – – High frequency, low intensity coaching Teaching starts with improved processes not personal exhortation 31

PCMH and the new chassis We can’t just stick new functions on the old chassis From Peek (2009) 32

Conclusion 1. We use Lean tools to build relationships and improve the chassis to carry the PCMH Lean Tools Trusting relationships Better chassis for care Better chassis for education 2. This allows us to make significant changes, build a trustworthy system, and maintain adaptive reserve in order to transform into a PCMH – including deep physician and staff identity changes. 3. This new “chassis” and the process of building it will actually enhance the resident education experience and build skills needed in the PCMH. 33

Acknowledgements and References Thanks go to Clinic staff, physicians, lean facilitators, and leaders from Broadway Family Medicine, Smiley’s Clinic, Bethesda Family Medicine, Phalen Village Clinic--and the Dept. of Family Medicine and Community Health. Thanks for engaging in this journey to change the chassis-- which been neither easy nor comfortable References Nutting P. , Miller, W. , Crabtree, B. , Jaen, C. , Stewart, E. , Stange, K. (2009). Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Annals of Family Medicine Vol 7, No. 3, May/June 2009 On the Mend, by John Tousssaint (Lean at Theda. Care--Appleton WI) Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience, by Charles Kenney (Lean at Virginia Mason--Seattle) David Mann (2005) Creating a Lean Culture: Tools to Sustain Lean Conversions Productivity Press, New York 34

Thank you! Questions and discussion For more information: Peter Harper: pharper@umphysicians. umn. edu Wendy Nickerson: WNICKRSN@umphysicians. umn. edu C. J. Peek: cjpeek@umn. edu 35