JKA Lean Healthcare Model
The JKA Lean Healthcare Model is designed to adapt to the needs, culture, and current capabilities of an organization. Understanding that lean represents a management system designed to provide the processes, tools, and internal capabilities to help leaders lead, managers manage and care teams provide care, the JKA model for Lean in Healthcare encompasses:
- Alignment to strategic objectives (Hoshin plans)
- Structure to support mobilization, implementation, and deployment of lean as a management system
- Culture/people development (executives, directors, managers, supervisors, and staff)
Performance Improvement – When applied properly, lean can deliver amazing (and quantifiable) results to an organization. Objectives such as: quality (core measures and outcomes), patient and staff satisfaction (Press Gainey), improved access (primary care, ED, surgery, neuro, etc), and financial performance (revenue, cost). When engaged properly, a lean management system provides:
- A process for communicating strategy, objectives, and process performance
- A system for front-line problem identification, prioritization, and problem solving
- A systemic approach to process improvement and improving performance (i.e., access, quality, satisfaction, utilization, financials, etc.)
- A process for knowledge capture and subsequent knowledge sharing across the organization
“You cannot change behavior by email.”
Most healthcare organizations struggle with the implementation and deployment of change and the subsequent sustainment of results. In the JKA model, we focus on the pathways to communicate and message to all affected constituents (RNs, MDs, staff, and leaders). Understanding that a great solution that is poorly deployed is in fact no solution at all is the key to understanding the importance of thoughtful and thorough deployment (i.e., gaining the buy in/confidence in the new process and the delivery and sustainment of results).
Understanding whether the process change affects 12 individuals in sterile processing or 212 clinical staff and 57 physicians that support the ICU is key to defining the complexities associated with the implementation and deployment of a solution.
JKA Healthcare Model Results
- Periop process across 4 hospitals and 30+ specialty practices improving on- time starts from 68% to84% and increasing OR capacity by 15%
- New central line process across 900+ bed hospital reducing Central Line Days by 20% and CLABSI rate by 82% ($4.2mm)
- Emergency department: reduced avg LOS 42%, Reduce LWBS 84% (<1.2%), increased volume 20%
- Implementation and deployment of new coding, billing, and charge capture process across 95 clinics, reducing time to bill, denials, and AR days ($3.6mm)
Key Components - Lean in Healthcare
- Leadership Development – Lean as a Management System includes the development of senior leaders, directors, managers, and supervisors in both performance management (dashboards, MDI, A3, Gemba walks) and process improvement.
- Process Improvement – Performance Improvement through the fundamental improvement of key processes is a core competency to be developed in any health system, hospital, medical group, and/or health plan.
- Lean Infrastructure – Having the processes and systems in place to not only lead and guide the appropriate selection and execution of process improvement activities, but more importantly to effectively document, spread, and scale solutions across departments, units, and locations is key tospeed to value.
- People Development – At its most basic level, we view lean as a people development Focusing not only on process improvement and results, but on the continual support and development of thinkersand learners throughout an organization.
Our approach in healthcare seeks to first understand an organization’s culture, business challenges, current organizational capabilities, payor models (current and future), and leadership teams appetite for change to ensure our approach, style and mobilization model are most appropriate aligned to our clients needs. Starting from a basic framework, the JKA model is designed to not only be customized to meet an organization’s needs (at launch), but also to ensure we leverage existing internal process improvement, organizational development and/or lean capabilities that already exist within the organization. The model we mobilize with any client, must be aligned to their organization and designed to evolve as our client’s skills and capabilities grow. It is this approach that has enabled JKA to avoid the shortcomings (and unnecessary costs) associated with one size fits all models.
Lean is often called learn by doing process by lean practitioners. However, too often this phrase is taken too far (e.g. one can only learn by doing). In our model, health systems, hospital and physician practices, represent the perfect opportunity for a learn from others model. A model ideal for shared learning across shifts, units, facilities and physician practices. In healthcare the types of opportunities and the root causes of so many front line delays and interruptions are common, common across all units or practices.
Why must we re-learn and run the same rapid improvement events over and over, with the assumption that we have learned little/nothing prior? Our approach emphasizes knowledge capture for it is with the capturing of lessons learned that an organization can begin to share lessons learned. It is our belief that knowledge transfer does not happen by osmosis, it must be integral to the approach and methodology from the outset. This approach has been key to implementing and deploying solutions developed at 1-2 pilot practices and deploying then across 50-70 practices throughout the medical group
Together, we work with our clients to best configure the choices and options associated with strategy, execution, training (leadership and staff), process improvement, lean events, projects, and people development. Viewing Lean as a component of a broader Management System is key to our developing and integrating foundational capabilities such as A3 thinking, Managing for Daily Improvement (MDI), huddles and gemba walks to yield timely, actionable and appropriate leadership and response. Key Senior and Operational leadership decisions will directly affect the areas of focus, pace of change, and breadth and depth of phase I (mobilization).
With only 9 out of 487 Medicare Advantage plans earning CMS “5 star” status, having two ‘5 star’ Medicare Advantage health plans as clients of JKA has afforded us an incredible opportunity; the opportunity to learn and apply lean principles to impact strategic objectives with best service and quality organizations in the world. The opportunity to apply Lean in support of population health, disease management, medical cost (from a payor perspective) and admin expense within health plans has given us the opportunity to work within and across the interfaces of payor, primary care, physician practices, hospitals, surgery centers, physicians, staff, care managers, case managers, social workers .. etc.
Our work with health plans has included commercial, government, Medicare and Medicaid and private health plans. We have worked in all key aspects of health plans including strategy, member enrollment, provider enrollment, member services, claims, credentialing, case management, reporting, HCC scores … etc. Understanding how improvements in and across each of these areas can be used to impact growth, admin expense, medical expense, patient safety and quality outcomes is the key.
Work specific to the unique characteristics of fully funded, self funded, ASO and IDN within commercial health plans has yielded key strategic opportunities for growth within existing geographies, new geographies, admin expense and medical management.
Our work with health plans has also helped us bridge the gap between payor-provider, plan-practice, and medical management and practice processes. How do we take the incredible data available with the health plans and translate the data into timely, actionable and appropriate information that can be used immediately at the practice level. How do we support practices in their pursuit of population health, patient health, medical expense and shared risk opportunities. How can we leverage new monies made available through shared risk agreements to fund telemedicine, group visits, community outreach, and healthy patient panels. How can we use Lean to help practices, providers and staff understand the real impact of the shift away from 99% Fee for Service towards 40%, 50% or 60% FFS and more importantly how this shift can work in their favor.
Hospitals and Hospital Systems
John Kim & Associates has been implementing Lean in Healthcare for 10+ years actively transforming Health Systems, Hospitals, Medical Groups, Physician Practices and Health Plans, and evolving our enterprise wide view of healthcare improvement. JKA’s experience includes 100+ hospitals, medical groups, home health, physician practices and health plans throughout the US, Canada, UK and Australia. Our model and approach for Lean in healthcare focuses on alignment of improvement efforts with your strategic, business, and operational objectives. When engaged, utilized and mobilized properly Lean provides a management system for an organization to achieve organizational goals and engage in ongoing incremental improvement.
JKA’s approach to Lean In Healthcare provides each client with not only improvements in process and department level performance, but more importantly solutions that impact the service line, care continuum and broader health system. JKA engagements include not only traditional process oriented and front line leadership improvements but also solutions designed to improve patient care (acute and emergent conditions) and patient health (primary care, population health, disease management).
Alignment with Strategic and Operational Objectives
Our work with clients begins with the senior leadership team to ensure any improvement efforts are aligned with strategic, operational, clinical and/or community objectives.
Common Business Objectives
- Access (hospital, service line, specialty, SNF and primary care)
- Quality (Core measures and Clinical outcomes)
- Patient / Staff / Physician Satisfaction
- Growth / Capacity / Revenue
- Cost (labor and/or material)
- Speed to market (new services or post acquisition integration of hospitals, practices, etc)
Approaches: Service line, Process, Project
Depending on the objective(s) selected, the opportunities at hand and current operational and improvement capabilities of the organization, the approach and areas of impact focus vary. Operational objectives can often be achieved with a process or project approach. System level objectives most often require a Service line approach.
- Service Line: Improving revenue in Orthopedics, Cardiology or Labor and Delivery for example would typically take a Service Line wide approach, as impacting the metric of revenue often comes from improving multiple parts of the value stream such as; improving access, increasing capacity, charge capture, and/or improving schedule utilization.
- Process: An objective such as improving ‘time to discharge’ or ‘reduce CLABSI incident rate’ would be examples of where we would focus on improving, piloting and demonstrating improvements to a common process, and subsequently deploy this process into many areas.
- Project: Improvements that are singular or concentrated in certain areas or that are impacted by relatively short value streams are often best approached as a project. Reducing ED wait time and LWBS, improving Sterilization turnaround time, developing a process for IV Pump Cleaning, and charge capture are examples of classic lean projects.
Patient Centered Medical Home
The Patient Centered Medical Home (PCMH) can be represented by a dynamic, fluid, proactive, responsive medical practice and extended groups of care teams. Highly coordinated care amongst many professionals requires high velocity communication, cross practice (cross functional) value streams, knowledge sharing and information flow. Understanding that achieving the highest ranking amongst NCQA measures can only be achieved through the identification, design and development of core practice processes and processes within and across the various care teams is the key.
The same processes used to communicate to providers gaps in care are also the same core processes that ensure A1C levels are checked, blood pressures are documented and that immunizations and screenings are up to date. It is not enough to have an EHR installed at a medical group, How the EHR is synchronized with key practice processes and how practice processes are synchronized with the capabilities of the EHR is how one ensures the pre admit, registration, rooming, exam, referral, and billing processes work seamlessly. Understanding, synchronizing, designing and planning the workflows that occur outside the patient visit is key to maintenance of patient records, coordination of patient information and the prevention of preventabledownstream work. Designing practice flows, multi specialty health centers and using 3P to optimize new designs and layouts is how one can eliminate many embedded wastes in practices.
Understanding that to be an effective PCMH, one must not only master the capture, coordination and flow of information, but also design the internal and cross practice (medical group) processes amongst many specialties, offices, care teams, scheduling guidelines and EHR systems. It is an organization’s ability to identify, develop, integrate and master key practice level processes across the care continuum (e.g. primary care, specialist, hospital, labs, home health, SNF, LTAC, etc) is how one will achieve the highest results associated with NCQA quality measures.
People & Culture
We start with the fundamental belief that in healthcare ‘our employees make good decisions today.’ It is with a certain degree of understanding, awareness and information upon which our staff and providers make their decisions. When observed closely, when presented with a given scenario, our staff, providers and employees make very consistent decisions … the best decisions they know how.
We believe that to ask our people to make different decisions without fundamentally changing the information and/or processes available to them is wrong. If we wish to change the types of decisions our people make, we owe it to our leaders and front line staff to design and build processes which (1) enhance their awareness and understanding of the situation and (2) improve the quality, clarity, timeliness and completeness of information and data they receive. It is with this improved understanding and improved information flow that our people will naturally make a more informed decision than they did before. We do not have to tell them to make a better decision … they will…
We see Lean in Healthcare as fundamentally being about people. In managing the true healthcare continuum, we must be able to effectively influence key people at key points in the decision making processes that influence patient care and the quality of care patients receive. We must be able to influence providers. We must identify and improve key processes (practice, hospital, information). We must be able to influence staff. Finally, and perhaps most importantly, we must be able to influence patients, as they are ultimately the ones responsible for their own bodies, lifestyles and personal decisions.
At John Kim & Associates, we have been privileged to work extensively with ACOs/IMOs, hospitals, medical groups, and physician practices. Engaging the people who perform the work and aligned with IHI’s Triple Aim Initiative, our engagements are focused on demonstrating results directly impacting patients, providers, health system, and payors.
We believe nearly all objectives, whether viewed from a patient, provider, health system, or payor perspective, stems from an organization’s ability to create access at all levels (without adding new physicians, staff, or facilities). Fundamentally, our approach represents a shift from a model based primarily in acute care (and annual physicals) towards a new paradigm of open access, core measures performance (90+% compliance), identifying and closing gaps in care, chronic disease management, and population health.
In addition, our work with health plans, IMOs, and ACOs has been vitally important for us in understanding how to integrate improvement across primary care, specialty care, and the broader health system. Additionally our engagements have taken us deep into fee schedules and payment models that are seeing a steady shift away from traditional fee for service and toward risk sharing agreements. With the proper understanding of core measures, population health and advanced models of care, reimbursement (revenue) can be generated in primary care for value provided outside of the traditional patient visit.
Our approach helps physician practices introduce new approaches to scheduling, care models, and use of mid-levels; thereby enabling care team(s) to focus on clinical, patient, and provider objectives. Understanding the staffing and scheduling nuances of pediatrics, family medicine, and internal medicine helps avoid ill-fitting formulas that too often drive staffing, length of visits, and revenue (RVU) targets. These new/modified models of care have opened the door for providers and staff to truly collaborate and focus on managing the health of patients resulting in breakthrough levels of improvement at many levels including:
- Access (Primary Care and Specialty Clinics)
- Revenue (with no new Physicians or Staff)
- NCQA Core Measures
- Collaborative Care
- Population Health and Chronic Disease Management
- Integrated Behavioral Health
- Group Visits
- Home Health/Post Acute Care
Recognizing the complexities that come with coordinating and deploying improvements across large physician groups (of 20+ clinics) has been paramount to JKA’s success. Understanding the dynamics and keys to success of a multi-specialty health center and how the approach and methodologies for improvement are fundamentally different than those associated with a hospital or primary care office is how we maximize ‘speed to value’ for each entity.
- “…Lean must earn its place at your leadership team’s table…” If Lean cannot demonstrate its ability to inherently help your leadership team(s) achieve their objectives better than the resources already available to them, then “Lean” is just another distraction. Conversely, if “Lean” provides a structure, provides focus, drives Implementation and delivers results faster, stronger and with less risk that what they do today, then Lean will be engaged by more and more of your organization. When engaged properly, Lean provides:
- A methodology for implementation (i.e. process improvement, employee engagement, sustainable results)
- A mechanism that stimulates both Interest and Curiosity (“… I never thought about it that way before…”)
- An Management System that enhances the capabilities of leaders and employees to identify and solveproblems
- Hospital ≠ Hospital ≠ Hospital: One of our greatest lessons learned is to respect the differences, nuances and uniqueness of every hospital service line and/or practice with a health system. Although true that many of the opportunities within a hospital are common and many solutions can be scaled, understanding the starting points with every group is imperative. Business factors such as hospital census level, market share, cost position are key to knowing where to begin and how fast we need to go. Cultural factors such as previous process improvement experience, leadership style, provider relationships, staff engagement are key to determining how fast you can go. Understanding that mobilizing lean in critical access, 700 bed, and academic hospitals are fundamentally different is key to avoiding preventable change management challenges.
- “… you cannot change behavior by email…” Change is all about people. This is true in any industry, but amplified in the healthcare. Physicians and care providers alike make local decisions, individual decisions, and independent decisions. Any (change) implementation strategy must understand the people dynamics of change. If we implement a change, how will we communicate it (i.e. deploy it) in such a way as to have the recipient understand, agree with and adopt the new process? Implementation and Deployment must bedesigned in to any improvement program. In our model, we start with the fundamental belief that our people make good decisions today. However with what level of understanding and awareness (of the business) or with what clarity, timeliness and accuracy of information are our employees making those decisions? We believe that it is the identification of the right information and the ability to design, implement and deploy the right processes that we can fundamentally enhance the quality and timeliness of decisions made by staff and care providers alike.
- “… no two Lean Journeys are the same…” Over the past 15+ years, this has been one of our biggest learning’s. Every organization (health system, hospital, service line, specialty, unit … etc) has its own challenges and local situations that deserve to be included in any discussion about strategy, direction, implementation and/or approach. There are no formulas. There are no “rules of thumb” that should driveany decision making about the structure, frequency or intensity of one’s lean journey. Criteria such as: business objective, business needs, senior leadership expectations, management-employee relationship, employee morale, change management history … etc are all key inputs in constructing any Lean strategy or mobilization plan. Choosing to use a ‘formula’ without first considering the inputs noted above (we believe) is shortsighted and has proven to extend learning curves, increase cost, increase risk and force organizations to repeat lessons that did not have to be re-learned.
- “Implementation and Deployment.” A common failure mode of most improvement programs in healthcare is the lack of structure associated with implementation and deployment of changes. With the complexity of hospital patient flows, all improvements must have an approach for mobilizing change that not only, implements locally (within a unit/department), but also effectively deploys across shifts, other units and other hospitals (or physician practices) in the system. In the absence of the specific capabilities to implement and deploy change, all changes are susceptible to fall back and rejection. More importantly, it is this model that actively seeks to capture and share experiences and improvement thus preventing hospitals and health system from having to learn (and pay for) the same lessons over and over again. In our model,knowledge capture and knowledge transfer are an active components of the learning cycle, and form the foundation for deploying improvements from one area-department-clinic to other floors and facilities.