The Phoenix Project

Integrating Effective Disease

Management Into Primary Care Using
Lean Six-Sigma Tools

John Oujiri, MD
Cynthia Ferrara, MS
St. Marys/Duluth Clinic Health System
 St. Marys/Duluth Clinic Health System (SMDC)

Integrated health system

Main Campus in Duluth,MN with
three neighborhood sites
16 regional clinics throughout
northeast MN and northwest WI
400+ physicians
 SMDC clinics
are located over
25,000 square
miles and serve a
population of
nearly half a
million people

18.7 people per

square mile

11.4% of
population below
poverty level
(2004)
 Goal of Phoenix Project

Develop a standard set of workflows for delivering

evidence-based care that provides a consistent
clinical experience for patients and a consistent
process for care teams.

Differentiate our organization to payers, employer

groups, and government agencies.
 Phoenix Lean Process Road Map
8. Control Phase On-going
Sustain and Continuous Improvement

7. Staged Implementation Pilot Sites 1-3 Feb 08-July 08

6. Report to Sponsors November 2007

5. Midway Report and Feedback August 2007

4. Sponsor Update Frequent

3. Weekly Action Meetings Start: June 2007

2. 4-Day Breakthrough Work-out June 2007

1. Pre-Launch Planning May 2007

 4-Day Breakthrough Work-Out

Cross-functional teams from pilot sites (3)

assembled to apply lean design concepts to
core processes and systems in four-day event.

Empowered to develop solutions/actions.

Core Breakthrough Team Members:

Staff and physicians from pilot sites and key
leadership.
 Value Stream Mapping
Captures the current reality
Defines value from customer
perspective
Forms the basis for an
implementation plan
Breakthrough Design Map
Major Process Steps
In Between Visit Activities and Pre Visit Planning Sub Process Assumptions & Open Questions
Developed in Workshop Philosophy: What about
by: ? Hospital or
Chris Human Provider
Assisted Living,
Mike Touch vs. Autonomy?
Nursing Home

Demonstrates waste,
Lisa Automated
Dennis Pts?
Krister
Assumption: Karen
Base of Schedules interaction
Outside via: Previsit Planning
patients Appointment
Labs? Intervention is: -Call - prior to day of, Check out
already IDd happens
Automated Triggers -Patient Specific -My Chart automatic scrubber should

gaps and major Automatically order of -Measurable -Kiosk @ mall determines needed tests inititiate the
needed test as future and & -Adjusted as needed - Clinic Kiosk and orders them in between
drive work effort (prioritize) - Home process
PROACTIVE
Risk Stratification -Must be
Role change of human to documented via Telehealth monitors
Out of Care PT technology email, letter or ? - B/P

constraints in care
- CHF
-Blood Sugars
REACTIVE
Safety Net?
Health Alerts
Care
Coordinator

delivery
Combining
Patient Coordinate
visit with all Med vs.
Center, Not
Identified Disease needed problem list
Patient Patient services scrubbing
Registry

Automated reporting
& Analysis Tools
Clarity on Steroids

Identifies value-added business

intelligence tools

Big Ideas and Enabling Tools:

steps needed
Need to
define
Policy/Leadership Decisions:
Patient Education: Community Integration System: Patient Kiosk: Key: Standardize Create a Problem Create a policy on
Resources!
Webcasts Example: vaccination In Clinic protocols and use List and Med List Outside Labs which
Podcasts program In retail locations them as much as Update Policy supports CCSI
Link to Comm. Resources Other public sites possible
Email
Staff Education and
My Chart
Development:
2004 Leap Technologies, Inc.
- Scripting
 Major Red Flags Identified
Lack of consistency across clinics in key
sub-processes, roles and workflows

Under-utilization of EPIC (Electronic Health Record)

capabilities and a variety of individual physician
solutions rather than a system solution

Daily mountains of rework by the most constrained

resources in Primary Care

Information Gaps at several critical points in the

delivery of Primary Care. Waste identified during
encounter and rooming process due to lack of any
pre-visit planning

Significant Patient Activation opportunity

 Four guiding principles developed
to help move from the current
process to an effective and efficient
model of care delivery.

Do the right thing. Do it right

 Phoenix Guiding Principles

Practice to the full scope Automate work That No

of licensure & abilities Human Should Do

Design Centralization into our Create and implement a Common

process wherever it makes sense Way of Doing Things across the
Duluth Clinic system
 Lean Strategies Applied
Visual Management
Use of simple signals and signs in EPIC
Standardization
Work gets done so that the outcomes are more
predictable
Mistake Proofing
Building error prevention into the design of the
process
Constraints Analysis / Bottleneck Reduction
Improving flow by designing to overcome
resource constraints. Move work forward
Automation
Taking routine tracking tasks out of the hands of
people and into EPIC
 Phoenix Primary Care Model Components
Productive Interactions
Informed, Activated Patient Prepared, Proactive Practice Team

Pre-Visit Planning
Schedule Appointment
Review Med List
Labs First Scheduled/Ordered
Health Maintenance Alerts
Between Visit Planning Visit Prep Questions
Out-of-range/Out-of-Contact Pts Info from Outside Providers

Day of Visit: Rooming

Vitals/Rooming Form
RN Coaching PATIENT Med List (Clarify)
BPA based on criteria Load & Pend Refills
Initially Diabetic Only Pend BPAs
Day of Visit: Clinician
Check Out Views all data
Prints AVS/Med List Reconciliation of Med List
Other RN DM Programs Future Appts Patient Instructions/follow-up
Warfarin; Diamond; Hypertension Referrals Dx and Orders
 Elements of the New Design:
Pre-Visit Planning

Centralized, pre-visit planning takes place for

every scheduled visit
Standard process, questions and protocols
Labs ordered per protocol
Health Maintenance alerts
Initial Med Review takes place before patient
appointment
 Elements of the New Design:
Check-in and Rooming

Lab First tasks are completed prior to rooming

A standardized rooming process
(i.e. socks/shoes off for diabetic visits,
BP measurement, depression screening)
Med Review by CA at rooming
Load and pend Best Practice Alerts for
physician order approval
 Elements of the New Design:
Physician/Credentialed Practitioner
Information needed for the encounter has
already been prepped for provider
Provider will:
Reconcile med list
Update Problem List
Make a follow-up appt plan with each visit
Enter future orders
Support patients behavior change efforts
Enter patient instructions
 Elements of the New Design:
Patient Activation

Health risk, knowledge and activation assessment

RN Coaching Model
Disease coaching and care coordination is a value-
added service that payers have been willing to
reimburse
Motivational Interviewing skills
Use of enhanced take-home patient instructions
Creation of a Disease Management Care Plan
EPIC / MyHealth online tools allow patients to
access their medical record, review labs, etc
 Elements of the New Design:
Check-Out

100% of patients are directed to check out

Every patient receives an After Visit Summary
Communicates what occurred during the visit
Includes instructions and updated Med List
Next appointment scheduled
Future labs ordered, per provider and protocol
 Process Steps and Perceived
Complexity
These additional up
front process tasks
represent
16
Prevention of
14 process rework and
delays on the day of
12 encounter
10
8
6
4
2
Appears to be
more 0
New
complexity in the 1
2 Old
front end of 3 Old
4
process 5 New
 Control Phase
Key Performance Metrics
*Balanced Scorecard/Strategy Map Measures

Process

% of patients with:
Completed pre-visit planning
Health Maintenance alerts satisfied
Lab orders complete
Medication list reviewed
RN coaching appointment (per selection criteria)
After Visit Summary, Med list and next appt scheduled
Clinical
* Optimal Diabetes Management: 25%

Customer Service
* Achieve 10% increase in overall patient satisfaction

Financial: Physician and Staff Productivity

* RVUs/Provider FTE
* Direct Operating Margin
* Encounters per Support Staff FTE
 Feedback to Care Teams

Routine reporting feedback loop

Data is provided at physician,clinic and system
level for all SMDC clinics
Incorporates evidence-based guidelines in
assessing quality performance
Process and outcome measurement, evaluation
and management
Data is transparent within the health system
 Diabetes Optimal Management
% of Patients Meeting All 7 Measures**
Phoenix Project Pilot Site 1
June 07-July 08
n=556
40
% of pts with diabetes meeting all measures

35

30

25
Implementation Feb 08
19.3
20
16.5 14.8
15
14.6 15.9 16.8
10

June 07 Sept 07 Dec 07 Mar 08 June 08 July 08

Dat e

(*) Includes: A1C in last 6 months Blood Pressure <130/80

A1C <7% Tobacco Free
LDL in last 12 months Anti-platelet use in patients over 40 y/o
LDL <100 mg/dL.
 Feedback to Physicians and Staff: Physician Level
DC-Clinic C
Diabetes Management
June 2007 June 2008
n=981
% of Patients with Diabetes with Blood Pressure <130/80
Target = 50%
100

90
% of providers' diabetic patient population

80

70

60

50

40

30

20

10

Clinic C

SMDC Primary
Dr.G
Dr.E
Dr.B

Dr.C

Dr.D

Dr.F
Dr.A

Care
Provider

Jun-07 Sep-07 Dec-07 Mar-08 Apr-08 May-08 Jun-08

 Encounters Per Support Staff FTE
Phoenix Pilot Site #1
250

214
205

200 190

174 172 171

156 153
149 149 152 151 149
143
150
Encounters

100

50
Implementation Feb 08

-
FY 2005 FY 2006 FY 2007 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008 FY 2008

July August September October November December January February March April May
Fiscal Period

Encounter Per Direct Support Staff FTE Poly. (Encounter Per Direct Support Staff FTE)
 Phoenix Project:
Impact on Disease Management
Integration of population-based disease management into routine
care
Decrease in missed opportunities for lab work and increased % of
patients up-to-date (A1C, LDL, etc)
Future appointments and labs scheduled before patient leaves the
clinic, whenever possible
Improved patient engagement in self-management
RN Coach: Alert fires within EHR for patients meeting criteria for referral
Patients receive After Visit Summary that clearly communicates what
occurred during their visit, including instructions and next steps
Prepared proactive care team
Lab results available at time of appt increase effectiveness of pt visit
Intentional and focused efforts to enhance disease management has
led to health plan collaboration and improved reimbursement
structure
 Ongoing Challenges
Change Management
There is nothing more difficult to carry out, nor more doubtful of
success, nor more dangerous to handle, than to initiate a new order
of things. Machiavelli, The Prince, 1513
Physician Engagement
Clinical Inertia
Unexplained Variance
Reluctance in system to hold individuals accountable for
implementation and results, i.e. culture of consequences
No Net New
Ensuring that efficiencies gained allow for value added activities
without increase in resources
Value must be defined by external customer (patients and
families) rather than internal (staff, physician, payers)
 Lessons Learned
Implementing lean thinking in a traditional health care culture is
not for the faint of heart (IHI)
Communication is essential
Do not underestimate the response to change in status quo
The vocal, unhappy minority cannot steer the ship
Senior leadership support is invaluable
Involve patients in planning process
Not a quick fix
Improvement to metrics will take time
Will require sustained commitment
Clear definition of roles and responsibilities will help project
move forward
You get what you expect and you deserve what you tolerate
Questions ?
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