Quality Improvement, Performance Management, and Outcomes: Lean Six Sigma for Integrated Behavioral Health

Abstract

The transition to value-based healthcare is shifting reimbursement for integrated behavioral healthcare from fee-for-service to value-based contracts that emphasize improved quality, efficiency, and outcomes. The Lean Six Sigma approaches to quality improvement are well-suited to meet these new criteria. Techniques such as the value stream map, the plan-do-study-act cycle, control charts, and the A3 Report are Lean Six Sigma approaches to quantifying value-based care, evaluating improvements over time, and initiating quality improvement efforts as needed. The competencies covered in this chapter reflect the importance of improving efficiency, decreasing waste, and improving outcomes in integrated behavioral healthcare delivery. Examples of measurement and evaluation of these competencies are included.

Appendices

Appendix A: Case Study Scenario

Case Study with Data for Assignment 1: Value Stream Map for Dr. Lynn’s Clinic

Instructions: Read this case study carefully. All of the data needed to complete the value stream map formulas are included in the case study. Your job is to create a value stream map of the current state based on this case study.

We met Dr. Lynn last week. She works in a busy urban primary care clinic staffed by an administrative assistant, a scheduler , four PCPs, two nurses, a physician assistant (PA), a medical assistant (MA), and a nutritionist. Dr. Lynn has decided to create a value stream map for process of a patient visit to the PCP, including a warm handoff to the BHP (Dr. Lynn).

Dr. Lynn consulted with all of the staff and identified a basic process map of each step from the time a typical patient first walks in the clinic door until the time the patient walks out of the clinic. Dr. Lynn completed a walk of the process from start to finish to complete the value stream map. All of the times below are based on averages provided by the staff. The times for each process step include the estimated initial first pass yield (PPY) percentage in parenthesis. Dr. Lynn determined the FPY for each process step based on feedback from the team member who is most expert on that step (e.g., administrative assistant for check-in, PCP for PCP interview, etc.).

All patients complete the My Own Health Report (MOHR) as part of their annual physical exam. If one is not on record, the administrative assistant will instruct the patient to complete it in the waiting room after check-in using an office tablet. The physician reviews the MOHR during the patient annual physical exam, but usually not during other visits. Dr. Lynn reviews the MOHR for each new patient. Dr. Lynn will also have the patient complete the full PHQ-9 and GAD-7 if the PHQ-4 that is part of the MOHR is positive. She does this in the session with the patient using a tablet for automatic scoring and feedback. Dr. Lynn may use other rating scales or patient education, self-monitoring, or other forms based on the presenting problem and treatment approach. The clinic has an electronic health record (EHR) system, and all staff enter notes and data for all encounters.

From the time the patient enters the office and approaches the nurses’ station, it is one minute. The check-in with the receptionist takes 4 min (FPY, 97%). The patient then waits in the waiting room for 14 min. Then the patient is called in to complete vitals with the PA, which takes 5 min (FPY, 95%). The patient returns to the waiting room and waits for an average of 12 min. Then the patient is called into the examination room for the nurse interview. The nurse interview takes 4 min (FPY, 90%). Then the patient waits in the examination room for an average of 17 min until the PCP arrives for the PCP examination. The PCP examination takes 12 min (FPY, 90%). The PCP then walked the patient to Dr. Lynn’s examination room and introduced the patient to Dr. Lynn. This takes 2 min. Dr. Lynn then completes the BHP interview that takes an average of 20 min (FPY, 85%). Upon completion of the BHP interview, the patient returns to the nursing station to check out. Then the patient leaves the office. The clinic is relatively small, so the average time to walk from waiting room to any exam room is 1 min.

Dr. Lynn made several observations during her consultation with the staff and during the process walk. First, Dr. Lynn identified the following high-level process steps:

• Check-in

• Vitals

• Nurses’ interview

• Physician exam

• BHP interview

• Checkout

Dr. Lynn also noted the following problems that appeared to contribute to lower first

pass yield (FPY) for each step, that is, problems in each step that resulted in the process step not being completed correctly the first time. During the check-in, the administrative assistant often forgot to ask patients who were there for their annual physical exam to complete the MOHR. During the nursing interview and physician exam, the MOHR results were usually reviewed by the nurse and PCP with the patient. However, the MOHR was not routinely readministered, while the patient was in treatment as a measure of treatment progress and reviewed by the nurse or physician. Dr. Lynn wondered if this should be an area of improvement. During the nursing interview and PCP exam, Dr. Lynn observed that patients were not routinely asked about medication side effects. She thought that this may be an area of quality improvement . During the physician exam, the PCPs typically did not review the MOHR on record for patients who were there for a sick visit.

Each PCP had their own approach to identifying the need for integrated behavioral health referral to Dr. Lynn. Dr. Lynn suspected that the decision-making processes for identifying and referring patients to her were not consistent between the PCPs and may be an area of improvement. Dr. Lynn also observed that sometimes patients were not clear why they were referred to see her in the warm handoff. Patients reported not being clear on her role and purpose of the referral. Dr. Lynn identified the need for improved patient information on her service, and perhaps a script for PCPs would be a potential area of improvement. During her own patient visits, Dr. Lynn noticed that she often spent too much time going over the MOHR and other rating scales she administered, leaving her feeling rushed to transition to the treatment planning, advising and assisting the patient to leave with a clear and agreed-upon plan of action for behavioral issues. Dr. Lynn reviewed the wait times between each process step and did not think that they were excessive for a busy clinic. However, she realized that she had not reviewed the clinic patient satisfaction data available on this topic. In addition, Dr. Lynn noted that while there were some magazines in the waiting room, they were older, and only a few subscriptions were available. She thought that having magazines in the exam rooms may also be helpful, and she wondered if a TV added to the waiting room would be helpful.

Appendix B: Group Activity #2 – Rapid Improvement Event

Use the discussion group thread for your group to contact your group members and schedule a meeting (teleconference, skype, etc.). For this group activity, you will practice a group Rapid Improvement Event.

• 1. Carefully read “Facilitating Rapid Improvements” Chap. 9 from “Executing Lean Improvements” by Delisle (2015). Each group member will prepare a Rapid Improvement Event (RIE) based on your quality improvement project for this class (the VSM, PDSA, and control chart).

• 2. Assign team roles to each member based on the roles under “Facilitation Guidelines” on page 158 (you may swap roles as each group member takes turns as “presenter”):

• Lead facilitator, process checker, scribe, timekeeper, and presenter

• 3. Each presenter will choose a technique from each of the five steps of the “Kaizen problem-solving process”

  • Step 1. Brainstorm issues and barriers.

  • Step 2. Filter and prioritize issues and barriers.

  • Step 3. Brainstorm solutions.

  • Step 4. Filter and prioritize solutions.

  • Step 5. Develop and implement the action plan using the “Action Plan Worksheet.”

• Note that each presenter will choose one of the multiple techniques listed under Steps 1–5 above. Also note that a number of techniques are designed for an in-person rather than telephonic meeting. You may choose an in-person technique provided that you can modify it for a telephonic meeting.

• 4. Each member will take a turn making their presentation based on the Kaizen problem-solving process. Note: Be brief, and modify each presentation so that you will complete your presentation and all steps in about 20 min. A real Kaizen problem-solving exercise would take at least 1 hour or more. For this assignment, I am interested in your ability to practice each technique briefly, but not to spend so much time that the duration of your group meeting is excessive. I recommend that the group agree on a time limit for each presentation and that the “timekeeper” announce in 5-min increments the time remaining.

• 5. Complete a final group thread posting. Note: You do not need to post a substantive reply for this assignment. The final group thread posting for each group member should include each of the following:

  • (a) Describe aspects of the group discussion from the perspective of a team-based approach to quality improvement. How did a group approach to planning your RIE add value? What are the benefits of the Kaizen problem-solving process? What are the problems or challenges of using the Kaizen problem-solving process?

  • (b) Post your “action plan template.” You can post as a summary narrative in the group thread; you do not need to use a table format as used in book example.

Appendix C: Group Activity PDSA Grading Rubric

PDSA group activity grading rubric
Category	Excellent 1	Good 0.75	Fair 0.50	Poor 0.25
Brief description of PDSA	Contains clear and concise description that includes aim, plan, do, and study	Contains general description that includes aim, plan, do, and study	Contains fair description that does not clearly include aim, plan, do, and study	Contains poor description that does not clearly include aim, plan, do, and study
Brief description of control chart	Contains clear and concise description of measure selected for control chart	Contains general description of measure selected for control chart	Contains fair description of measure selected for control chart	Contains poor description of measure selected for control chart
Brief description of your presentation and discussion	Contains clear and concise description of your experience in presenting and discussing your PDSA/control chart. Clear description of how feedback influenced your plan for assignment	Contains general description of your experience in presenting and discussing your PDSA/control chart. General description of how feedback influenced your plan for assignment	Contains fair description of your experience in presenting and discussing your PDSA/control chart. Not clear how feedback influenced your plan for assignment	Contains poor and concise description of your experience in presenting and discussing your PDSA/control chart. Not stated how feedback influence your plan for assignment
Clarity and mechanics	Excellent. No grammar or spelling errors. Excellent organization	Good. One grammar or spelling error. Good organization	Fair. More than one grammar or spelling error. Fair organization	Poor. More than one grammar or spelling error. Poor organization