Physicians are confronting challenging times in their own practices and in the hospital environment, from new government mandates, new technologies, myriad of databases and quality measures, to new payment models driven by the value reimbursement concept. Change is everywhere in the American healthcare system; physicians, clinicians and administrators face the massive challenge of navigating shifting landscapes, increasing revenues, decreasing expenses and achieving healthier patients. Recent changes in U.S. healthcare legislation are influencing hospitals to purchase formerly independent physician practices to more closely integrate expenses and billing within the overall hospital system.
The ASQ Healthcare Division developed a five-step model in 2015 to transform clinical offices into effective units for delivering improved patient outcomes while reducing costs. This improvement model is effective for both hospital-integrated physician operations as well as independent clinical practices. The model uses the Modular Kaizen approach to reduce disruption in daily processes using Lean concepts.
The five-phase journey begins with assessing the current state of physician practices. A validated practice assessment tool is used to analyze current operations of the practice. When the physician practice is integrated into a hospital setting, this journey becomes a system-wide journey to minimize disruption, reduce costs and improve interacting processes. This assessment becomes a baseline for the level of maturity of the practice based on the five phases illustrated in Figure 1. Sustainability plans are developed and reinforced with each practice for long-term improvement tracking and self-sufficiency. The clinical practice moves from one phase to the next as it demonstrates achievement of the qualitative and quantitative milestones of each phase. Periodic reassessments using the validated assessment tool measure practice capability and maturity covering domains in:
- Quality improvement
- Operational efficiency
- Clinical administrative and financial improvement
- Use of data
- Coordination level with other institutions, clinicians and specialists
- Patient involvement and patient satisfaction
The transformation target within the physician’s relationship with the hospital is for improved effectiveness in serving patients while reducing costs. Reducing disruptions in daily operations frees up professionals to perform core processes rather than fight fires. It is recommended that hospital leadership choose only a few high priority physician practices or teams for the first round of improvements. Even improvement can create disruption if not properly managed.
The five phases of developing clinical and administrative outcomes are a progressive journey toward improved patient outcomes and reduced costs. The phases are described below.
The chief medical officer (CMO) starts by setting the overall vision and outcomes expected in his hospital. The scope of the physician’s unit under study is defined and overarching goals identified. No effort will be successful without employees knowing what must be achieved. Once direction is set, the next action is to develop a structured set of processes to meet expected outcomes. Modular Kaizen focuses strongly on this Phase 1 planning stage. Direction, process definition, training and tools are the foundation of any successful journey. This initial planning and structural definition is essential to accomplish the remaining four steps.
Once the practice has a reliable operating structure, current activities are measured to verify that desired results are achieved. If results do not meet patient and regulatory requirements, priorities are set to improve, starting with the most critical outcomes. Measures allow employees to “see” the most valuable improvements based on data collected and analyzed.
Using data and improvement tools, either already in use by the hospital or introduced by the Modular Kaizen team, the practice focuses on the critical few problems that will yield lower costs, give better care to the patients and achieve better health outcomes.
The focus of improvement is to get to a level of performance that consistently meets patient and regulatory requirements. This benchmark status is particular to each medical practice team based on complexity factors such as care specialties, number of employees, number of patients or level of practice maturity.
The learning and improvements achieved through the previous phases have created a stable and reliable clinical practice. The physician or clinical team is sustainably and reliably reducing costs, increasing profitability, eliminating waste and providing a better level of service and better health to patients.
The sustainability function of a stable operating process includes constant monitoring of performance to assure the process still meets patient requirements within normal limits. The Modular Kaizen approach to continuous and breakthrough improvement offers healthcare leadership a set of tools for achieving and sustaining this stable operating environment.
MODULAR KAIZEN IMPROVEMENT MODEL
Modular Kaizen is a modification of the traditional Kaizen improvement process designed to provide rapid results without removing critical personnel from daily operations.1 It is conducted over a series of short activities designed to fit into a highly interrupt-driven work environment like a physician’s practice or hospital department. The tools of Modular Kaizen assist improvement teams to gather and analyze data about disruptions to expected activities and make informed choices about returning to a stable system. Minimizing disruptions to normal clinical processes is what allows the practice to improve outcomes and reduce costs through the five phases of the transformation model.
Modular Kaizen has been successfully applied through both the traditional Plan-Do-Check-Act (PDCA) cycle and the more recent Lean Six Sigma (LSS) family of improvement cycles.2 The Modular Kaizen flow using the Lean Six Sigma DMAIC approach is shown in Figure 2.
The Define phase of the DMAIC (define, measure, analyze, improve and control) is used to investigate a situation to see if a disruption to the expected workflow has a special cause or whether it is a normal variation of a standard process. In the LSS DMAIC cycle, this monitoring is performed during the “measure” phase of the improvement process.
The next step is “analyze.” Based on the data gathered in “measure,” the response team does one of the following:
- Do nothing. Continue to monitor the disruption until it has either dissipated or needs more attention. If more analysis is required, establish a team to investigate the disruption (analyze) and report back.
- Respond by taking short-term actions that apply all available resources to stabilize the process. The full DMAIC cycle is employed to solve the disruption and bring it under control.
Modular Kaizen minimizes disruptions by making sure no “analysis” is executed until “measure” has been done to establish the baseline measurement of where a disruption begins. When any action is taken, it is done in an informed manner. The analysis is short term, based upon a comparison of expected process performance with data gathered from the actual performance experienced.
The Define phase of the DMAIC cycle identifies changes to the process intended to prevent the disruption from occurring again. This second cycle of measure, analyze and improve validates (measures) the final improved outcome and employs the control phase of the cycle to document the changes for future sustainability. This small M, A and I cycle is the basis of Modular Kaizen within the Lean Six Sigma improvement cycle.
The best approach to support physicians and specialists to improve outcomes is to give them the tools they need to make changes that most benefit their patients. Healthcare quality professionals must collaborate with physicians to develop solutions that meet cost-saving requirements based on their specific situations. Improvements must be customized to each practice based on the physician’s patient and administrative requirements.
Historically, the medical community knows how technical capability is obtained, but has difficulty defining how administrative competence is achieved. A long- term, continual pursuit of quality improvement in a business requires a structured method to focus on the problem beyond a subjective, ad hoc solution. Healthcare has the same business challenge. Physicians rarely are trained to run the administrative side of their practice. Modular Kaizen provides training to top clinical and administrative management to change the leadership paradigm, clearly identify roles and responsibilities, apply systems thinking, inspire and align with mission, minimize disruptions, and empower hospital employees to better meet patient needs. When processes are defined, measured and continuously improved, the practice runs smoothly, as a business should.
- R. Bialek, G. Duffy, and J. Moran, Modular kaizen, Public Health Foundation, 2011
- Duffy, G. L. ,Modular Kaizen: Continuous and Breakthrough Improvement, Quality Press, Milwaukee, WI, 2014
- Ibid, pg. 66