Lean Six Sigma, care coordination heals fragmented hospital

Under healthcare reform, a new trend of care coordination management is developing across hospitals, primary care provider offices, home health agencies, and patients' homes. Hospitals are taking a more active role in what happens to patients--especially those with chronic conditions--after discharge, as reimbursements are tied to readmission rates. Care coordinators follow patients and work with other healthcare professionals in hopes that they won't return. So far, some of the leading hospitals are experimenting with the concept and showing impressive results.

For example, University of California, San Francisco, found that transitional care programs with nurse coordinators helped reduce readmissions of older heart failure patients by 30 percent and helped save Medicare $1 million per year, according to researchers.

Similarly, Mercy St. Vincent's Medical Center in Toledo, Ohio, improved quality thorough its own care coordination model while incorporating Lean Six Sigma principles. This safety-net hospital improved outcomes and saved on costs, following improvements of care coordination, implementation of a culture of efficiency, data-rich technology, and real-time operation performance measurement.

Ben Sawyer

Ben Sawyer

Lean Six Sigma approach
In a gist, Lean Six Sigma approaches look at what the customer wants, while assessing value and nonvalue. The aim is to eliminate that nonvalue and recreate work flow with standardization to increase positive impacts for the customers, that is, patients.

"Hospitals on a daily basis are paralyzed by the urgent so they can't get to the important," said Ben Sawyer, executive vice president of hospital software provider Care Logistics. Using the principles of Lea Lean Six Sigma can help identify and unlock the system constraints that blocks optimal performance, he added.

A holistic approach
Mercy St. Vincent aimed to reduce waste, wait times, nonvalue-added work, and rework and develop a set of new standard operating procedures, measures, and milestones. When it started the improvement initiatives in 2007, it found, like many health systems, its work and therefore quality measures were unit-specific and didn't always paint a true picture of the performance of the whole organization.

Imran Andrabi

Imran Andrabi

"What was lacking was this coordination of the entire system that was centered around the patient," former Mercy St. Vincent CEO Dr. Imran Andrabi told FierceHealthcare. (He is now senior vice president and chief physician executive officer of Mercy Health Partners and senior vice president of clinical innovation for office of operations and systems effectiveness for Catholic Health Partners.) "The care coordination model was developed out of a principle that required us to--as we took a step back--to look at the entire system. We were going to do away with the fragmentation that is even within a single system."

The hub of it all
Key to the operational changes is what they call the "care coordination hub," a physical location in the hospital to manage patient flow logistics--from admission to discharge--24/7.

Described another way, as Andrabi pointed out, the hub is the air traffic controller and the care coordinator is the pilot. "They are constantly in touch with each other so you know what's happening at every instance," he said.

Each unit has a clinical care coordinator, who acts as local agent in the emergency room or operating room and coordinates with the hub to ensure the most efficient use of capacity at a system level. The unit care coordinators are nurses or registration workers, a contemporary merged version of the traditional charge nurse and case manager role.

Care coordination hub

Care coordination hub

"Nurses in the current healthcare structure are expected to be the internal primary care coordinator for the patient, and yet, to a large extent, are disempowered. They don't always know how long the patient is authorized to stay and those details that normally reside in case management," said Sawyer at Care Logistics, which worked with Mercy St. Vincent's and Catholic Health Partners. "The care coordinator role is actually the merging of the case manager and charge nurse into one. And when they're asked to do something, they're empowered to make it happen and to execute it within that hub model."

Although some hospitals are experimenting with patient navigators or care coaches who might not have a clinical background, it's critical for the nurse care coordinator to have medical knowledge, thus breaking down the silos of healthcare, Andrabi explained. However, the care coordinator could work with patient navigators if hospitals use them as part of the care team.

Care coordinators work on admissions, bed assignments, unit transfers, and discharges. They also provide a daily touch point with physicians, ensuring availability of necessary lab results and consult reports, as well as working with the doctor to ensure proper documentation. For patients, the care coordinator also sets length-of-stay targets and reviews the daily plan with patients and their families so they are all on the same page with a so-called end in mind.

Patient satisfaction, outcomes results
How did patients react to the model? When asked if patients would recommend Mercy to friends and family, 76 percent reported they would recommend the hospital, while state and national averages are at 69 percent.

Mercy St. Vincent's also increased core measure performance by 37 percent, reduced infection rates by nearly half (49 percent), and reduced preventable harm by 72 percent.

The new model did come with some challenges though, namely underdoing years of siloed work between departments and provider and healthcare worker roles. However, with early buy-in, leaders and front-line workers together created the vision of the initiative from the beginning and with regular dialogue. Initial Gallop Poll results indicate that front-line staff members also are more engaged.

"They feel like they are heard, that they are part of an improvement process" Andrabi said. "Hopefully, we are on the right track in creating a system that not only works for our patients but for our caregivers."

Some medical staff did have a "show-me" attitude, Andrabi said, but that's where performance data comes in. Rather than retrospective reports that are 30 days or older, real-time data showed providers the results of the changes. It was "transformational," according to Sawyer.

Mercy St. Vincent's model can be replicated at other institutions, big and small. The principles are all the same--inside, outside, and in between hospitals, Andrabi explained.

Tips for implementing a care coordination model at your institution
Start early. Mercy St. Vincent's started from scratch, designing and implementing at the same time, and the process took 14 to 18 months. However, starting early, especially for large institutions, allows great impact and benefits. For instance, identify potential care coordinators early on.

Break down the silos. Using Lean Six Sigma principles in silos is an exercise in futility, Sawyer said. Hospitals should commit to functioning like a system. For example, Mercy St. Vincent's CEO rounded on a weekly basis, which is a huge, but worthy, change, he added.

Have a vision. What is ultimately the most important thing that your organization wants to deliver? That varies for different hospitals, but it's important to clearly define that vision. "If you don't know what the end is, you don't know how to get there," Andrabi said.

Commit. "We put the human systems in place before the technology. This is not a technology fix," Andrabi added. Commitment from the entire organization creates a sustainable system over time. "There are no silver bullets. This is hard work," he said.  

Editor's note: For more information on the care coordination model, you can download a presentation, "Lowering Costs and Improving Quality through Total Hospital Efficiency," hosted by Fierce Live! Webinars. - Karen (@FierceHealth)