Does your physician practice have what it takes to be lean?

For decades now, we've heard about manufacturers and retailers running Lean or Six Sigma or whatever you want to call it—putting workplace processes from scheduling to supplies management under the scalpel to carve away excess overhead, inefficiencies, and redundancies.

In the past few years, larger hospitals and health systems have bought into the process, and now a growing number of physician practices have embraced Lean, including Kalamazoo, MI–based Borgess Ambulatory Care (BAC).

"It is an intense effort, and it works," says Ed Millermaier, MD, MBA, chief medical officer and COO at BAC. "Breaking down processes into individual steps is daunting work. We're learning that we need to focus on pieces of the process so we can measure improvement and track ourselves. This is a long-term process; there are no quick wins."

It's also a very time-consuming process that requires a lot of expert help, which may prove to be the biggest challenge for many physician practices that want to go Lean. BAC, with 58 physicians and 16 offices, didn't do it alone. It had help from Lean experts at the University of Michigan Health System and funding and guidance from Blue Cross Blue Shield (BCBS) of Michigan.

"It is very difficult to truly embrace the principles of Lean without help. I don't think you need a major institution, but you may need some outside consultation or education assistance," Millermaier says. "One could argue that, for the small physician practices, doing this on your own could be more challenging."

BAC used consultants identified through the BCBS physician group incentive program who all had a background in Lean. They were experts who brought their experience from Fortune 500 companies to the organization, Millermaier says. Those experts provided BAC physicians and staff with analytic principles and tools of the Lean process, which allowed them to strip down the typical office day into a series of individual steps. They mapped out the steps needed to complete everything from incoming calls to sick visit scheduling to filing paperwork—then they improved those processes.

At the end of the initial review, the wait time for pediatric well visits was reduced from 60 days to eight days, and mammography patients saw their wait times for follow-up testing after initial screening drop from 19 days to three days. The practices also created efficiencies in medical records filing, storage, and response time.

The value stream map
To identify process inefficiencies, BAC dissected an everyday event: a newly diagnosed diabetic patient scheduling a nonurgent return visit. Staff members walked through the process from start to finish, using everyone involved in the visit—from the receptionist to the physician—to create a value stream map that identified 13 steps needed for a successful encounter.

"The more steps you have, the more opportunities you have for the whole event to not be a complete and accurate event," Millermaier says. "By day two, we had it narrowed to nine steps. We got rid of a bunch of rework on the telephone because we realized the schedule wasn't out far enough to accommodate needs of the patients. We looked at all the silly stuff we do to accommodate the schedules and the physicians stepped up to say, 'This is crazy. We want the schedule out 13 months to account for annuals.' "

The process worked in part because BAC selected staff and providers who would not have problems leaving their titles at the door and focusing on flow, Millermaier says. "The physicians were willing to hear, 'Gee, Doc, when you do that with the chart, I can't find it. When I can't find it, I can't meet the need of the patient.' The medical records clerks were willing to hear that they had to reorganize their medical records. The insights that they got on how to fix flow problems were enough that they could clean up the medical records process. They figured it out on their own. Those were line associates, not the managers."

Tom Leyden, manager of clinical program development at BCBS Michigan, said the Lean program began in June 2008 and now includes approximately 8,000 physicians from about 100 large physician groups in the Lean Professional Collaborative Quality Initiative.

Not every physician group is ready for Lean, Leyden says.

"Once they express their interest, there is a readiness assessment where the coordinating center out of U-M Health System meets extensively with the physician group to determine if they're ready to embrace Lean," he says. For some organizations, it might be a three- to six-month process to determine whether there is strong organizational support for it and to start thinking about what they want to address.

Leyden says BCBS Michigan will fund any Lean program in the ambulatory setting that will improve quality of care and advance the practice "along the path to a fully functioning patient-centered medical home."

BCBS Michigan fully funds three value stream mappings for physicians' groups, which usually take more than 18 months to complete. Consultants' fees are paid by the insurer, which also provides the physicians' groups with about $15,000 to provide compensation for any temporary disruptions to practice work flow.

"The expectation is that each organization will have at least one person who will become the internal Lean coach. It's a 'see one, colead one, do one' approach," Leyden says.

In the first value stream mapping session, the internal Lean coaches observe. In the second value stream mapping, they colead the whole three-day session, the 30-day report out, and the 60- and 90-day reports, working closely with the consultants. In the third value stream mapping, the Lean consultants have it pretty easy. They watch and provide some pointers, but it is the physician organization that does the work.

Outside expertise
"Sometimes the best Lean coaches are the people who haven't had a background in quality improvement or process improvement previously," Leyden says. "It is based on their interest and desire and ability to effectively implement change." So far, Leyden says BCBS Michigan has spent about $2 million funding physician Lean programs in the past two years.

And what bang does the health insurer get for its buck.

"We get improved quality of care for our members, reduced readmissions," he says. "The better the physician organizations use their disease registries, the better care is delivered. Hopefully that results in less [emergency room] visits, in less patient stays, and things of that nature."

Despite its origins in the manufacturing sector, Millermaier believes Lean is a good fit in medicine.

"The principles of Lean can apply," he says. "None of the Lean consultants had a healthcare background when they started with us. They brought to us a perspective around business operations that is challenging for us in medicine, particularly for physician leaders. It is not an area that we are strongly trained in."

"Once you get past the notion of the widget manufacturers coming in to commoditize healthcare, it teaches us how to be more effective and efficient in what we are doing," Millermaier adds. "And it aligns very much with the Institute for Healthcare Improvement's Triple Aim when you look at optimizing the patient experience, improving the population's health, and keeping costs per capita under control."

Torrance, CA-based HealthCare Partners Affiliates Medical Group has acquired Talbert Medical Group, Inc., a physician-owned practice with more than 67,000 managed care patients in Los Angeles County and Orange County. Financial terms of the deal were not disclosed in a media release announcing the acquisition.

The acquisition increases patient base for by HealthCare Partners in California to 750,000 and expands patient access to more than 1,200 primary care physicians throughout the Los Angeles Metro area, HealthCare Partners said.

"Talbert Medical Group strengthens our presence in Los Angeles County and expands our geographic coverage into Orange County, allowing us to provide quality, cost-effective healthcare for a growing number of Californians," said Robert J. Margolis, MD, HealthCare Partners chairman/CEO. "We are excited about what a great organization like Talbert, with its 40-year history of healthcare leadership and delivery of quality medical care, brings to our combined organization."

Keith Wilson, MD, Talbert's president/CEO, has been named regional medical director of HealthCare Partners' operations extending into Orange County.

Talbert owns 10 medical offices located in Anaheim, Compton, Downey, Fountain Valley, Huntington Beach, Lakewood, Long Beach, Santa Ana, and Tustin, and four walk-in centers in Anaheim, Compton, Fountain Valley, and Long Beach.

HealthCare Partners has more than 1,200 employed and affiliated primary care physicians and more than 3,000 employed and contracted specialists. HealthCare Partners also operates urgent care centers, medical spas, and an ambulatory surgery center.

Many non-profit hospitals don't do enough to tell needy patients they may qualify for charity care programs, or how to apply for help, according to a report released today by The Access Project and Community Catalyst.

The report, Best Kept Secrets, examines whether non-profit hospitals are meeting the voluntary guidelines established by the American Hospital Association for billing and collections for uninsured and underinsured patients.

AHA guidelines call on hospitals to have clear, written policies to help patients determine if they qualify for charity care and to make these policies available to patients and the public.

Best Kept Secrets is based on a 2009 national survey of 99 randomly selected non-profit hospitals that was conducted by The Access Project. The survey found that while most hospitals mentioned their charity care programs on their Web sites or over the telephone, only 25% provided eligibility information. Less than half provided a charity care application form, and less than 1 in 10 hospitals listed discounts for income levels on their Web sites.

"This report illustrates that voluntary guidelines are ineffective," said Access Project director Mark Rukavina. "Given the state of our economy and the insecurity Americans feel regarding healthcare costs, hospital charity care is and will continue to be an important part of our healthcare safety net. Both federal and state governments must ensure that hospitals receiving tax breaks are also fulfilling their charitable obligations."

The federal healthcare reform law requires tax-exempt hospitals to establish and publicize financial assistance policies that clearly specify eligibility criteria. They are also banned from taking extraordinary collection actions before making a reasonable effort to determine if patients qualify for financial assistance.

Jessica Curtis, director of the Hospital Accountability Project at Community Catalyst, called the report "surprising and disappointing given that hospital billing and collection practices have been closely scrutinized over the last decade by Congress and many state governments."

"It will be important for the federal government to develop regulations that establish very clear standards for tax-exempt hospitals and then monitor hospital behavior to ensure that they comply with the new requirements," Curtis said.

Hospitals take their mission of caring for the uninsured and underinsured "very seriously," the AHA said in a statement repsonding to The Access Project's report.

"Today's report is out of sync with field practices and the health reform legislation, which we supported," AHA officials said in the statement. "The legislation includes provisions similar to AHA's voluntary guidelines. From conversations with our members, we know that there is a great deal of time and energy dedicated to helping the uninsured and that hospitals are constantly developing new and better ways to communicate with the uninsured and underinsured."

The Medical Center at Bowling Green (KY) is notifying 5,418 patients of a breach of personal health information after the theft of a computer hard drive from the hospital's mammography unit. The hard drive contained data on patients who underwent bone density testing at The Medical Center between 1997 and 2009.

"We have no reason at this point to believe the device was stolen for the information on it or that any personal information has been released or used," the hospital said in a statement posted on its Web site.

The personal information on the hard drive was not encrypted, the hospital said.

The Medical Center staff discovered the theft on April 1, launched an internal investigation, and reported the theft to local police. Information in the hard drive includes each patient's full name, date of birth, address, medical record number, and physician name. Some patients' records also include Social Security numbers, weight, height, and menopause age.

"As a result of this breach, steps are underway to further strengthen the security of patient information," the hospital statement read. "We will now archive data to a secure network, which will allow us to eliminate the need for use of a hard drive like the one that was stolen. Additionally, we will ensure that we do not have any other equipment configurations that utilize a portable hard drive containing non-encrypted data."

The hospital is urging affected patients to monitor accounts and bank statements each month and check credit reports on a regular basis, and has notified the Department of Health and Human Services about the breach.