Lean Six Sigma – IntakeProcess StreamliningPresented by : Nathan McKenzie, Christine Peneyra, Manpreet Bhella

Why Integrate Lean & Six Sigma?Copyright NOVACES, LLC. All rights reserved.

Lean: A Strategy and PhilosophyCopyright NOVACES, LLC. All rights reserved.

Six Sigma

The Hidden “Factory”Copyright NOVACES, LLC. All rights reserved.

Understanding ProcessCopyright NOVACES, LLC. All rights reserved.

Intake Process BackgroundDuring the intake process, candidates are being asked similar questions regarding past historyby the enrollment team, intake RN, intake team and SB/EB (South Bay/East Bay) IDT.SF Region: 12 of 32 topic questions (37.5%) are asked by 4 or more of the 5 team membersSB/EB Region: 29 of 32 topic questions (90%) are asked by 3 or more of the 9 team membersSF Region: 5 hrs total assessment timeSB/EB Region: 6hrs total assessment timeBy analyzing the redundancy identified during the Lean Six Sigma assessment process, theintake team can assess the potential impact a reduction in assessment time will have on healthcare hospitality initiative goals, team efficiency in assessing new candidates and organizationalproductivity with non-intake related tasks.

Rapid Improvement Event (RIE)The RIE is an approach to team-based problemsolving and helps teams focus on processproblems Describe the current state Identify gaps & problems (wastes) Brainstorm solutions Define the future state Implement as much as possible and develop aplan for remaining items

SIPOCSUPPLYINPUTPROCESSIntake ProcessOUTPUTCUSTOMERSWho supplies theprocess inputs?What inputs arerequired for theprocess to functionproperly?What are the majorsteps in the process?What are the processoutputs?Who receives theoutputs?-Intake Coordinator-Enrollment Specialist(ES)-Intake RN-Intake Tean Manager-MD/SW/OT/PT/PM/HCRN/ RD-Center coordinator (SF)-MBHC-Front Desk/CenterCoord.(SB/EB)-OL CG (SB/EB)-Medical Records-Transportation-Activity Dept.-Inquiry receivedthrough calls, events,emails, referrals- Intake form andhome visit requestcreatedScreening by ES, IntakeRN, SW (entire teamSB/EB)-Documentation in EHRor Salesforce-Complete level of careform and submissionto MR, then to State-State decision w/in 5business days or less-Transfer summarysent to ProgramManager (SF)-Schedule EnrollmentConference & updateenrollment record-HV,FV, MD/SW assess(all assess)-Initial Contact w/EnrollmentSpecialist/IntakeCoord.-In-person meeting(tour, friendly visit)-Home Visit by IntakeRN & ES-Eligibility assessment& care plan meeting:·Intake team (SF)·Entire team(SB/EB)·30th St.: HomeCare visits candidateshome beforeenrollment-State submission-Enrollment conference(OT/PT assessmentcompleted SF region)-Candidate enrolls withOnLok-Candidate withdraws-Team denial-State denial/approval-Candidate-Family-Caregiver-Intake Coordinator-Enrollment Specialist-Intake RN-Intake team Manager-MD/SW/OT/PT/PM/HCRN/ RD-Center coordinator (SF)-MBHC-Front Desk/CenterCoord.(SB/EB)-OnLok Caregiver(SB/EB)-Medical Records-Transportation-Activity Dept.-Outside agencies

TIMWOOD 7 DEADLY WASTESCopyright NOVACES, LLC. All rights reserved.


Perform a Value Analysis

Perform a Value Analysis (cont)BUSINESS VALUE ADDVALUE ADDTHEMESTHEMES updates Assessments Deferrals Medical records review Referrals Communication withcandidates Mental health assessment Home visit State approvals TB tests Level of Care (LOC) form Enrollment meetings Care plan meetings Friendly visit Friendly visits Enrollment conference Home visits by Intake RN Transfer summary (SF) MD & SW assessments

Perform a Value Analysis (cont)WASTETHEMES Post enrollment-extra HC visit (30th) Follow-up assessmentExample: POWELL center waitlist few months. F/U visit needed as candidate health may have changed Candidate withdraws Candidate decides not to give up IHSS or PCP Lack of interpreter Different assessments scheduled on different dates Limitations of physical space (internal: conference rooms, desk space, dedicated space for privacy) TRAVEL TIME: home visits, center to center, large territory TIME: assessments by different team members, couples assessments, home visits, waitlist process Change in health status Decision making capacity (fail fast-how to determine sooner) Redundancy of questions being asked by enrollment team to cdt Conflicting history reports within IDT On-going call to cdt to determine interest level TMAHC process

ROOT CAUSE ANALYSISIncreased cycle time(Active & Wait) -FISHBONE(mother nature, measurement,machine, materials, manpower,method)

RIE Outcomes IDT team members and Lean Six Sigma Green/Black Belts held a 3days long work session. 2 new intake process improvement initiatives were identified by theIDT team Standardization of assessment questions Customized assessments Addition of intake coordinators

RIE Outcomes - Team Take OnsSTANDARDIZATION-universal document for all to view-remove redundant questionsWhy we should do it? Reduction in assessment time Reduction in duplicate efforts Increase in team morale

RIE Outcomes - Team Take OnsCOORINATOR / USING RESOURCES WELL-coordination between ES, PM, & IDT-admin support-review medical records (software?)-provide meals & activities calendar (Just Do It)-determine if all MR is needed-requesting MR more precisely (Just Do It)-pre-review of MR: tabbing/sortingWhy we should do it? IDT needs help with administrative tasks that are shared amongdifferent team members.

RIE Outcomes - Team Take OnsCUSTOMIZED ASSESSMENTS-minimum assessment set-buy in-borderline “unsafe” candidateWhy we should do it? Make the process Lean (reduction of waste)

LSS Intake and Enrollment Tiger Team Members

Current State1) Initial Contact w/ Enrollment Specialist/Intake Coordinator2) In-person meeting (tour, friendly visit)3) Home Visit by Intake RN & Enrollment Specialist4) Eligibility assessment & care plan meeting:Intake Team (SF)Entire team (SB/EB)30th St.: Home Care visits candidate home before enrollment conference5) State submission6) Enrollment conference7) (OT/PT assessment completed SF region)

Future State RIE Recommendation1) INITIAL CONTACT2) FRIENDLY VISIT3) CUSTOMIZED What is minimum?ASSESMENTIDT rep at this time? Buy In for borderline “unsafe” cdtFloat assessment?4) STATESUBMISSION5) IDT ASSESSMENTCARE PLANNINGENROLLMENT CONFERENCE

Future State – Intake Process

Data: Total potential candidates (SB/EB) What is known: 166* candidates between January to August 2019 65% conversion rate of candidates from home visit to state approval 35% drop out rate (100% potential candidates – 65% conversion rate) Current total candidates for 2019: 166 (from January to August 2019 75% of2019) Assuming trend remains: multiply by 25% for remainder of year (September – December2019) Potential total candidates per year 166 x 0.25 41.5 potential participants for September toDecember 2019. Round 41.5 to 42 potential participants from September to December 2019 Total potential candidates for all of 2019 208 (166 current 42 potential) Total potential dropouts 73 (rounded from 72.8) 208 potential candidates x 35% drop out rate 72.8* Data gathered from SalesForce

DATA: Assessment time for team (SB/EB) Baseline disciplines for assessments: 2 (MD & SW) Additional disciplines utilized for assessments: 5 disciplines RN PT OT AT RD 2.5 hours* of total assessment time across all five disciplines Time spent assessing potential drop outs: 182.5 hours 22.8 work days 4.6 work weeks 2.5 hours x 73 potential drop outs (from previous slide) 182.5 hours of assessment time 182.5 hours of assessment time/8 hours average work day 22.8125 work days (round to 22.8) 22.8 work days/5 days average work week 4.56 work weeks (round to 4.6)* Data gathered from LSS Pre-RIE survey

DATA: Assessment time per discipline What we know: 2.5 hours* per assessment x 73 potential drop outs 182.5 hours of assessment22.8 work days4.6 work weeks Calculations: time of assessment/73 drop outs # hours/8 hours per work day # work weeks/5 days in work week (all figures rounded): RN:45 min per assessment (0.75/hour) x 73 potential drop outs 54.75 hours 6.84 work days 1.37 work weeks PT:30 min per assessment (0.5/hour) x 73 potential drop outs 36.5 hours 4.56 work days 0.91 work weeks OT:30 min per assessment (0.5/hour) x 73 potential drop outs 36.5 hours 4.56 work days 0.91 work weeks AT:30 min per assessment (0.5/hour) x 73 potential drop outs 36.5 hours 4.56 work days 0.91 work weeks RD:15 min per assessment (0.25/hour) x 73 potential drop outs 18.25 hours 2.28 work days 0.46 work weeks --------------------------------Total combined 2.5 hoursper assessment* Data gathered from LSS Pre-RIE survey182.5 hourshours of total assessment22.8 work daysof assessments4.56 work weeksof assessments

Data: cost savings Combined average compensation for all 5 disciplines per hour: 174.18* HCRN PT OT AT RD 174.18 Total compensation cost for assessment time: 435.45 2.5 hours of assessment time x 174.18 discipline cost per hour 435.45 Total compensation costs for potential dropouts: 31,787.85 435.45 cost per assessment x 73 potential dropout candidates annually 31,787.85POTENTIAL SAVINGS 31,787.85 PER YEAR*Data gathered from On Lok HR

Success Metrics – Standardization of EHR Current state - Redundant questions SF Region: 12 of 32 topic questions (37.5%) are asked by 4 or more of the 5team members. SB/EB Region: 29 of 32 topic questions (90%) are asked by 3 or more of the 9team members Standardization of Electronic Health Records Customized assessments less redundant questions Universal electronic health records document for eligibility assessments IDT will use information collected from other disciplines for the purpose of eligibilityassessments.

Success Metrics – Intake Coordinator Current state – IDT members are fulfilling the administrative role to coordinate-between ES, PM, & IDT-admin support-review medical records-determine if all MR is needed-pre-review of MR: tabbing/sorting Re-evaluate and re-distribute the job roles of IDT and/oradministrative staff and see if certain tasks can be assigned to otherstaff.

Change d productivity andefficiency amongst staff-Increased transparencybetween intake dept.-Reduction in task duplication-Decreased frustration from cdtfrom redundancy of questions-Decreased candidateassessment time-Improved cdt experience-Increase in the capacity toenroll new cdts-Leadership team will have theability to easily manage astandard intake process acrossall regions-Decreasing utilization of centerresources-Cumulative assessmenttime reduced by 20%-Increased IDT assessmentcapacity per day-Increasing IDT productivityoutside of intakeassessments-increased employeesatisfaction-increased cdtsatisfaction/experience-Meet census goals-Increase conversion ratebetween stages of theenrollment process-Change management guidedby process owners-Present to organization:senior team,managers/supervisors-IDT team will need to befamiliar with intakeassessments topics/questionsfrom all departments-How to use Electronic HealthRecords system-Coordinator position:knowledgeable aboutindividual healthcare needs ofcdts in pipeline. Determinemost appropriate course ofaction-Involve Medical Records, IT, PL-Coordinator position:knowledgeable about individualhealthcare needs of cdts inpipeline. Determine mostappropriate course of action-Change management guidedby process owners-Identify process owners/champion involvementReinforcement-Project Manager-Develop a control plan:-process standardization-documented procedures-process capability-monitoring plan-response plan-process audits-Identify process owners-Champion involvement

Lessons Learned Charter – Keeping an open mind for all project activities. Edit project charter based on new findings, RIE discussion, organizationalfocus. Change Management - Receptiveness to RIE findings once Tiger Teamprojects were launched. Addressing change management for additional RIE recommendations. Green Belts/RIE/Tiger Team members’ availability. Lean Six Sigma Green Belts – Conflict of interest. Assign a Project Manager in the beginning of a project.


By analyzing the redundancy identified during the Lean Six Sigma assessment process, the intake team can assess the potential impact a reduction in assessment time will have on health care hospitality initiative goals, team