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LEAN Enterprise Methods in Healthcare:

VA Boston Mental Health

Jordan Peck

LAI Annual Conference

March 25, 2010

(2)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

2

VA Mental Health – Boston

ESD.62J/16.852J: Integrating the Lean Enterprise

Ellen Czaika

Clayton Kopp

Orietta Verdugo

Zakiya Tomlinson

Jordan Peck, Facilitator

(3)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

3

Agenda

Project Overview

Enterprise Description

X-Matrix

Process Waste

(4)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

4

Project Overview

Collect Data

11 individuals interviews

Phone and site interviews—Brockton, Bedford, Jamaica Plains

Metrics, process and procedure, organizational charts, financial statements

Conduct Analysis

Validate Findings

Formulate Recommendations

Present Recommendations

Project

Approach

Analyze the VA BMHS through a Lean assessment and suggest strategy for a Lean

transformation

Project

Goals

(5)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

5

To serve the veteran through the delivery of timely quality care by staff who

demonstrate outstanding customer service, the advancement of health care

through research, and the education of tomorrow's health care providers.

Mission &

Vision

Serve Boston Health Services

Team-oriented and Integrated Care

Quality Improvement

Compliance

Evidence-based Care through Educational Residencies

Become World Class Research Hospital System

Accessible Care

Strategic Goals

Boston Mental Health Service is largest within VA New England region

Locations – Brockton, Jamaica Plains, West Roxbury + CBOCs

Services – Inpatient, Outpatient, Residential Programs

Overview

(6)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

6

Organization Chart

Director

Director

Dir. of Impatient &

Transitional

Programs

Dir. of Impatient &

Transitional

Programs

Director of

Outpatient Service

Director of

Outpatient Service

Associate Director of

Outpatient Service

Associate Director of

Outpatient Service

Dir. of Residential &

Vocational Programs

Dir. of Residential &

Vocational Programs

Chief Psychology

Chief Psychology

Associate Director of

Mental Health

Services

Associate Director of

Mental Health

Services

Director of

Residency Training

Program

Director of

Residency Training

Program

Program Support

Assistant

Program Support

Assistant

Psychiatrist

Psychiatrist

Clinical Associate

Clinical Associate

Boston Health

Boston Health

Mental Health

Mental Health

VA New

England

VA New

England

Veteran

Affairs Office

Veteran

Affairs Office

Key Insights

Funding and strategic planning is driven from the top down

Programming and research is volatile and dependant on politicians

Communication channels between each enterprise

Key Insights

Funding and strategic planning is driven from the top down

Programming and research is volatile and dependant on politicians

(7)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

7

Financials

Key Insights

Budgets are based on previous years number of patients and number of

complex patients

(8)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

8

Universities & Residents

Stakeholder Value Comparison

Doctors

Pharmacy

Hospital Management

Employees

VA Leadership

Community

Politicians

Finance

Volunteers

Homeless Shelters

Patients

Supply Chain

Partner Hospitals

Tax Payers

High

Low

High

E

n

ter

p

ri

se

V

a

lu

e

D

el

iv

er

y

t

o

S

ta

ke

h

o

ld

er

Stakeholder Relative Importance to Enterprise

VA BMHS

Lean Insights

(9)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

9

(10)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

10

(11)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

11

2 2 2 2 2 2 2 2 1 2 0 2 2 2 1 1 1 4 4 2 2 2 1 3 1 12 2 3 1 5 4 4 4 4 4 4 5 5 5 4 4 5 4 5 6 4 3 0 1 5 3 0 2 1 3 23 1 1 0 1 6 6 6 6 6 6 7 7 6 6 4 7 7 7 7 5 4 4 5 7 5 2 3 4 4 35 3 4 1 6 01313 s s s s s s s s s s s s s

Serve Boston Healthcare

System s s s w w w w s w ww w s 1358 01212

s s s s s s s s s s s s

Team Oriented - Integrated

Care s s s s w s w s ws s w 1284

01313s s s s s s s s s s s s s Quality Improvement s s s s w w w w 8 44

01313s s s s s s s s s s s s s

Complience -VA Code of

Patient Concern & JCAHOw s w w w 5 14

12012

w w w w w ww w w w w w

Evidence Based Care (inc. Through Educational

Residencies) s s s s w s s ws s s w w

1394

11011w w w w w ww w w w w

Become W orld Class

Research Hospital w w s s s s ws s s s w w 1385 056 s s s s s Accessible Care s s w s w w s s w w sw w w w 1569 V oc at iona l I ndus tr y P rogr am S ubs tanc e A bus e O ut pat ient P rogr am S ubs tanc e A bus e I nt ens iv e O ut pai tent P rogr am R es ident ial P rogr am ( R E A C H ) M H IC M P rogr am -D ay P rogr am M et hadone C li ni c M ent al H eal th O ut pat ient Im pat ient S er vi c e W ai ti ng T im es -C lin ic T obac c o M eas ur e MH : S MI -M HI CM Ca p a c it y M ent al H eal th A c c es s M ent al H eal th M eas ur e C or rec tnes s of di agnos is and tr eat m ent T im el ines s of di agnos is and tr eat m ent Q ual it y of pat ient ex per ienc e ( m ini m a l di s c om for t r es pec tf ul et c ) T im el y and ac c ur at e i nf or m at ion fl ow S af et y /S ec ur it y of pr em is es C lean, H igh Q ual it y F ac il it y A c c ur at e P at ient R ec or ds A vai labi lit y of m edi c at io ns , s uppl ies , and equi pm en t O per at ing w it hi n budget F ai r W ages for s er vi c es S uf fi c ient Inpat ient and O ut pat ient C apac it y R eas onab le ex pec tat ions and res pec tf ul tr eat m ent of em pl oy ees R es ear c h A dv anc em ent K now le dg e T rans fer C om m u ni c a ti o n and Im pl em ent at io n of V A c ul tur e and val ues E ff ic ient R es our c e M anagem ent A c c ur at e and w el l-doc u m en ted m onet ar y tr ans ac ti ons U ps tandi n g m em ber of l oc al c om m un it y 000 Transfer from VA ER to Inpatient s w s w 4 22

000 Transfer from Urgent Care

to Inpatient s w s w 4 22

000 Transfer from Outside ER

to Inpatient s w s w 4 22

101 w Inpatient Treatment s w s s w w 6 33 000 Transfer from Inpatient to

Residential s w s w 4 22

011 s Discharge from Inpatient w s w s w 5 23 011 s Residential Treatment s w s s w w 6 33 000 Transfer from Residential to

Inpatient s w s w 4 22

011 s Discharge from Residential s w s w 4 22 000 Transfer to Outside Facility s w s w 4 22 3811s s s w ws s w s s s Outpatient Treatment s w s s w w 6 33

000 Referral to Inpatient s w w w 4 13

000 Referral to Residential s w w w 4 13

011 s W alk-in to Outpatient s w s w 4 22

000 Purchasing (Supplies &

Services) s s w s 4 31 000 Patient Data Managements w s s w w s s s 9 63 000 Research w w w w s s s s s w 1055 000 Facilities and Maintance s s s s s sw w w s 1073 000 Quality Assurance s s w w s s w w s 9 54 000 Payroll s w w w s 5 23 000 Human Resources s w s s s s w 7 52 1 1 1 1 1 1 1 1 4 1 1 1 1 9 16 15 7 1 3 3 2 9 21 3 3 3 21 2 3 1 1 1 1 0 0 1 0 4 0 1 1 1 7 9 5 5 1 1 3 2 5 110 1 1 4 2 1 0 0 0 0 1 1 0 1 0 1 0 0 0 2 7 10 20 2 0 0 4 1 3 2 2 17 02

X-Matrix

Metrics StakeholderValues

Key Processes Strategic Objectives

Metrics StakeholderValues

Key Processes Strategic Objectives

Stakeholder

Values

Key

P

ro

cesses

Enterprise

Metrics

Str

a

te

g

ic

G

oa

ls

Very strong alignment with

most metrics on target

Goals are not formal or

documented

Research is a goal but not

measured locally

Metrics vs. Objectives

Values vs. Goals

Strong alignment with

areas in service, care, &

research

Gap lies in aligning goals to

values such as:

Operating within budget

Well-documented

monetary transactions

Strong alignment in areas

of service, research, &

quality

Processes addressing the

least stakeholder values

are primarily patient

movement

Processes vs. Values

Strong alignment with

outpatient treatment and

clinic wait times

Missing metrics for key

processes

Transfers to inpatient

Program referrals

Metrics vs. Processes

Strong Alignment

Weak Alignment

(12)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

12

X-Matrix

2 2 2 2 2 2 2 2 1 2 0 2 2 2 1 1 1 4 4 2 2 2 1 3 1 12 2 3 1 5 4 4 4 4 4 4 5 5 5 4 4 5 4 5 6 4 3 0 1 5 3 0 2 1 3 23 1 1 0 1 6 6 6 6 6 6 7 7 6 6 4 7 7 7 7 5 4 4 5 7 5 2 3 4 4 35 3 4 1 6 01313s s s s s s s s s s s s s

Serve Boston Healthcare

System s s s w w w w s w ww w s 1358 01212

s s s s s s s s s s s s

Team Oriented - Integrated

Care s s s s w s w s ws s w 1284

01313s s s s s s s s s s s s s Quality Improvement s s s s w w w w 8 44

01313

s s s s s s s s s s s s s

Complience -VA Code of

Patient Concern & JCAHOw s w w w 5 14

12012

w w w w w ww w w w w w

Evidence Based Care (inc. Through Educational

Residencies) s s s s w s s ws s s w w

1394 11011

w w w w w ww w w w w

Become W orld Class

Research Hospital w w s s s s ws s s s w w 1385 056 s s s s s Accessible Care s s w s w w s s w w sw w w w 1569 V oc at iona l I ndus tr y P rogr am S ubs tanc e A bus e O ut pat ient P rogr am S ubs tanc e A bus e I nt ens iv e O ut pai tent P rogr am R es ident ial P rogr am ( R E A C H ) M H IC M P rogr am -D ay P rogr am M et hadone C li ni c M ent al H eal th O ut pat ient Im pat ient S er vi c e W ai ti ng T im es -C lin ic T obac c o M eas ur e MH : S MI -M HI CM Ca p a c it y M ent al H eal th A c c es s M ent al H eal th M eas ur e C or rec tnes s of di agnos is and tr eat m ent T im el ines s of di agnos is and tr eat m ent Q ual it y of pat ient ex per ienc e ( m ini m a l di s c om for t r es pec tf ul et c ) T im el y and ac c ur at e i nf or m at ion fl ow S af et y /S ec ur it y of pr em is es C lean, H igh Q ual it y F ac il it y A c c ur at e P at ient R ec or ds A vai labi lit y of m edi c at io ns , s uppl ies , and equi pm en t O per at ing w it hi n budget F ai r W ages for s er vi c es S uf fi c ient Inpat ient and O ut pat ient C apac it y R eas onab le ex pec tat ions and res pec tf ul tr eat m ent of em pl oy ees R es ear c h A dv anc em ent K now le dg e T rans fer C om m u ni c a ti o n and Im pl em ent at io n of V A c ul tur e and val ues E ff ic ient R es our c e M anagem ent A c c ur at e and w el l-doc u m en ted m onet ar y tr ans ac ti ons U ps tandi n g m em ber of l oc al c om m un it y 000 Transfer from VA ER to Inpatient s w s w 4 22

000 Transfer from Urgent Care

to Inpatient s w s w 4 22

000 Transfer from Outside ER

to Inpatient s w s w 4 22

101 w Inpatient Treatment s w s s w w 6 33 000 Transfer from Inpatient to

Residential s w s w 4 22

011 s Discharge from Inpatient w s w s w 5 23 011 s Residential Treatment s w s s w w 6 33 000 Transfer from Residential to

Inpatient s w s w 4 22

011 s Discharge from Residential s w s w 4 22 000 Transfer to Outside Facility s w s w 4 22 3811s s s w ws s w s s s Outpatient Treatment s w s s w w 6 33 000 Referral to Inpatient s w w w 4 13 000 Referral to Residential s w w w 4 13 011 s W alk-in to Outpatient s w s w 4 22 000 Purchasing (Supplies &

Services) s s w s 4 31 000 Patient Data Managements w s s w w s s s 9 63 000 Research w w w w s s s s s w 1055

000 Facilities and Maintance s s s s s sw w w s 1073 000 Quality Assurance s s w w s s w w s 9 54 000 Payroll s w w w s 5 23 000 Human Resources s w s s s s w 7 52 1 1 1 1 1 1 1 1 4 1 1 1 1 9 16 15 7 1 3 3 2 9 21 3 3 3 21 2 3 1 1 1 1 0 0 1 0 4 0 1 1 1 7 9 5 5 1 1 3 2 5 110 1 1 4 2 1 0 0 0 0 1 1 0 1 0 1 0 0 0 2 7 10 2 0 2 0 0 4 1 3 2 2 17 0 2

2

2

2

2

2

2

2

2

1

2

0

2

2

4

4

4

4

4

4

5

5

5

4

4

5

4

6

6

6

6

6

6

7

7

6

6

4

7

7

0

13

13

s

s

s

s

s

s

s

s

s

s

s

s

s

0

12

12

s

s

s

s

s

s

s

s

s

s

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s

0

13

13

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13

13

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11

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Serve Boston Healthcare System

Team Oriented - Integrated Care

Quality Improvement

Complience -VA Code of Patient

Concern & JCAHO

Evidence Based Care (inc. Through

Educational Residencies)

Wai

ti

ng Ti

m

es

C

lini

c

Tobac

c

o M

eas

ur

e

M

H

: S

M

I

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H

IC

M

C

apac

ity

M

ental

H

eal

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c

c

es

s

Become World Class Research

Hospital

Accessible Care

V

oc

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onal

Indus

tr

y

P

rogr

am

S

ubs

tanc

e A

bus

e O

utpati

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ethadone C

lini

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M

ental

H

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Im

pati

ent S

er

v

ic

e

Metrics

Stakeholder

Values

Key Processes

Strategic

Objectives

Metrics

Stakeholder

Values

Key Processes

Strategic

Objectives

(13)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

13

X-Matrix

2 2 2 2 2 2 2 2 1 2 0 2 2 2 1 1 1 4 4 2 2 2 1 3 1 12 2 3 1 5 4 4 4 4 4 4 5 5 5 4 4 5 4 5 6 4 3 0 1 5 3 0 2 1 3 23 1 1 0 1 6 6 6 6 6 6 7 7 6 6 4 7 7 7 7 5 4 4 5 7 5 2 3 4 4 35 3 4 1 6 01313s s s s s s s s s s s s s

Serve Boston Healthcare

System s s s w w w w s w ww w s 1358 01212

s s s s s s s s s s s s

Team Oriented - Integrated

Care s s s s w s w s ws s w 1284

01313s s s s s s s s s s s s s Quality Improvement s s s s w w w w 8 44

01313

s s s s s s s s s s s s s

Complience -VA Code of

Patient Concern & JCAHOw s w w w 5 14

12012

w w w w w ww w w w w w

Evidence Based Care (inc. Through Educational

Residencies) s s s s w s s ws s s w w

1394 11011

w w w w w ww w w w w

Become W orld Class

Research Hospital w w s s s s ws s s s w w 1385 056 s s s s s Accessible Care s s w s w w s s w w sw w w w 1569 V oc at iona l I ndus tr y P rogr am S ubs tanc e A bus e O ut pat ient P rogr am S ubs tanc e A bus e I nt ens iv e O ut pai tent P rogr am R es ident ial P rogr am ( R E A C H ) M H IC M P rogr am -D ay P rogr am M et hadone C li ni c M ent al H eal th O ut pat ient Im pat ient S er vi c e W ai ti ng T im es -C lin ic T obac c o M eas ur e MH : S MI -M HI CM Ca p a c it y M ent al H eal th A c c es s M ent al H eal th M eas ur e C or rec tnes s of di agnos is and tr eat m ent T im el ines s of di agnos is and tr eat m ent Q ual it y of pat ient ex per ienc e ( m ini m a l di s c om for t r es pec tf ul et c ) T im el y and ac c ur at e i nf or m at ion fl ow S af et y /S ec ur it y of pr em is es C lean, H igh Q ual it y F ac il it y A c c ur at e P at ient R ec or ds A vai labi lit y of m edi c at io ns , s uppl ies , and equi pm en t O per at ing w it hi n budget F ai r W ages for s er vi c es S uf fi c ient Inpat ient and O ut pat ient C apac it y R eas onab le ex pec tat ions and res pec tf ul tr eat m ent of em pl oy ees R es ear c h A dv anc em ent K now le dg e T rans fer C om m u ni c a ti o n and Im pl em ent at io n of V A c ul tur e and val ues E ff ic ient R es our c e M anagem ent A c c ur at e and w el l-doc u m en ted m onet ar y tr ans ac ti ons U ps tandi n g m em ber of l oc al c om m un it y 000 Transfer from VA ER to Inpatient s w s w 4 22

000 Transfer from Urgent Care

to Inpatient s w s w 4 22

000 Transfer from Outside ER

to Inpatient s w s w 4 22

101 w Inpatient Treatment s w s s w w 6 33 000 Transfer from Inpatient to

Residential s w s w 4 22

011 s Discharge from Inpatient w s w s w 5 23 011 s Residential Treatment s w s s w w 6 33 000 Transfer from Residential to

Inpatient s w s w 4 22

011 s Discharge from Residential s w s w 4 22 000 Transfer to Outside Facility s w s w 4 22 3811s s s w ws s w s s s Outpatient Treatment s w s s w w 6 33 000 Referral to Inpatient s w w w 4 13 000 Referral to Residential s w w w 4 13 011 s W alk-in to Outpatient s w s w 4 22 000 Purchasing (Supplies &

Services) s s w s 4 31 000 Patient Data Managements w s s w w s s s 9 63 000 Research w w w w s s s s s w 1055

000 Facilities and Maintance s s s s s sw w w s 1073 000 Quality Assurance s s w w s s w w s 9 54 000 Payroll s w w w s 5 23 000 Human Resources s w s s s s w 7 52 1 1 1 1 1 1 1 1 4 1 1 1 1 9 16 15 7 1 3 3 2 9 21 3 3 3 21 2 3 1 1 1 1 0 0 1 0 4 0 1 1 1 7 9 5 5 1 1 3 2 5 110 1 1 4 2 1 0 0 0 0 1 1 0 1 0 1 0 0 0 2 7 10 20 2 0 0 4 1 3 2 2 17 02

0

0

0

0

0

0

0

0

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0

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M

ental

H

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Wai

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Transfer from VA ER to Inpatient

Transfer from Urgent Care to Inpatient

Referral to Inpatient

Transfer from Outside ER to Inpatient

Inpatient Treatment

Transfer from Inpatient to Residential

Discharge from Inpatient

Residential Treatment

Transfer from Residential to Inpatient

Discharge from Residential

Transfer to Outside Facility

Outpatient Treatment

Referral to Residential

Walk-in to Outpatient

Human Resources

Purchasing (Supplies & Services)

Patient Data Management

Research

Facilities and Maintance

Quality Assurance

Payroll

Metrics

Stakeholder

Values

Key Processes

Strategic

Objectives

Metrics

Stakeholder

Values

Key Processes

Strategic

Objectives

(14)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

14

X-Matrix

s

w

s

w

4

2

2

s

w

s

w

4

2

2

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4

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9

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10

5

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10

7

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7

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16

15

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2

13

3

3

21

2

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7

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5

5

1

1

3

2

5

1

10

1

1

4

2

1

2

7

10

2

0

2

0

0

4

1

3

2

2

17

0

2

U

ps

tandi

ng m

em

ber

of l

oc

al

c

om

m

uni

ty

Transfer from VA ER to Inpatient

C

or

rec

tnes

s

of di

agnos

is

and

tr

eatm

ent

Ti

m

el

ines

s

of di

agnos

is

and

tr

eatm

ent

R

es

ear

c

h A

dv

anc

em

ent

K

now

ledge Tr

ans

fer

Q

ual

ity

of pati

ent ex

per

ienc

e

(m

ini

m

al

di

s

c

om

for

t, r

es

pec

tful

, etc

.)

Ti

m

el

y

and ac

c

ur

ate i

nfor

m

ati

on fl

ow

S

afety

/S

ec

ur

ity

of pr

em

is

es

C

lean, H

igh Q

ual

ity

Fac

ili

ty

R

eas

onabl

e ex

pec

tati

ons

and

res

pec

tful

tr

eatm

ent of em

pl

oy

ees

C

om

m

uni

c

ati

on and Im

pl

em

entati

on

of V

A

c

ul

tur

e and v

al

ues

E

ffi

c

ient R

es

our

c

e M

anagem

ent

A

c

c

ur

ate and w

el

l-doc

um

ented

m

onetar

y

tr

ans

ac

ti

ons

Transfer from Urgent Care to Inpatient

O

per

ati

ng w

ithi

n budget

Fai

r Wages

for

s

er

v

ic

es

S

uffi

c

ient Inpati

ent and O

utpati

ent

C

apac

ity

A

c

c

ur

ate P

ati

ent R

ec

or

ds

A

v

ai

labi

lity

of m

edi

c

ati

ons

, s

uppl

ies

,

and equi

pm

ent

Referral to Inpatient

Transfer from Outside ER to Inpatient

Inpatient Treatment

Transfer from Inpatient to Residential

Discharge from Inpatient

Residential Treatment

Transfer from Residential to Inpatient

Discharge from Residential

Transfer to Outside Facility

Outpatient Treatment

Referral to Residential

Walk-in to Outpatient

Human Resources

Purchasing (Supplies & Services)

Patient Data Management

Research

Facilities and Maintance

Quality Assurance

Payroll

Metrics

Stakeholder

Values

Key Processes

Strategic

Objectives

Metrics

Stakeholder

Values

Key Processes

Strategic

Objectives

(15)

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© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

15

X-Matrix

2 2 2 2 2 2 2 2 1 2 0 2 2 2 1 1 1 4 4 2 2 2 1 3 1 12 2 3 1 5 4 4 4 4 4 4 5 5 5 4 4 5 4 5 6 4 3 0 1 5 3 0 2 1 3 23 1 1 0 1 6 6 6 6 6 6 7 7 6 6 4 7 7 7 7 5 4 4 5 7 5 2 3 4 4 35 3 4 1 6 01313 s s s s s s s s s s s s s

Serve Boston Healthcare

System s s s w w w w s w ww w s 1358 01212

s s s s s s s s s s s s

Team Oriented - Integrated

Care s s s s w s w s ws s w 1284

01313s s s s s s s s s s s s s Quality Improvement s s s s w w w w 8 44

01313s s s s s s s s s s s s s

Complience -VA Code of

Patient Concern & JCAHOw s w w w 5 14

12012

w w w w w ww w w w w w

Evidence Based Care (inc. Through Educational

Residencies) s s s s w s s ws s s w w

1394

11011w w w w w ww w w w w

Become W orld Class

Research Hospital w w s s s s ws s s s w w 1385 056 s s s s s Accessible Care s s w s w w s s w w sw w w w 1569 V oc at iona l I ndus tr y P rogr am S ubs tanc e A bus e O ut pat ient P rogr am S ubs tanc e A bus e I nt ens iv e O ut pai tent P rogr am R es ident ial P rogr am ( R E A C H ) M H IC M P rogr am -D ay P rogr am M et hadone C li ni c M ent al H eal th O ut pat ient Im pat ient S er vi c e W ai ti ng T im es -C lin ic T obac c o M eas ur e MH : S MI -M HI CM Ca p a c it y M ent al H eal th A c c es s M ent al H eal th M eas ur e C or rec tnes s of di agnos is and tr eat m ent T im el ines s of di agnos is and tr eat m ent Q ual it y of pat ient ex per ienc e ( m ini m a l di s c om for t r es pec tf ul et c ) T im el y and ac c ur at e i nf or m at ion fl ow S af et y /S ec ur it y of pr em is es C lean, H igh Q ual it y F ac il it y A c c ur at e P at ient R ec or ds A vai labi lit y of m edi c at io ns , s uppl ies , and equi pm en t O per at ing w it hi n budget F ai r W ages for s er vi c es S uf fi c ient Inpat ient and O ut pat ient C apac it y R eas onab le ex pec tat ions and res pec tf ul tr eat m ent of em pl oy ees R es ear c h A dv anc em ent K now le dg e T rans fer C om m u ni c a ti o n and Im pl em ent at io n of V A c ul tur e and val ues E ff ic ient R es our c e M anagem ent A c c ur at e and w el l-doc u m en ted m onet ar y tr ans ac ti ons U ps tandi n g m em ber of l oc al c om m un it y 000 Transfer from VA ER to Inpatient s w s w 4 22

000 Transfer from Urgent Care

to Inpatient s w s w 4 22

000 Transfer from Outside ER

to Inpatient s w s w 4 22

101 w Inpatient Treatment s w s s w w 6 33 000 Transfer from Inpatient to

Residential s w s w 4 22

011 s Discharge from Inpatient w s w s w 5 23 011 s Residential Treatment s w s s w w 6 33 000 Transfer from Residential to

Inpatient s w s w 4 22

011 s Discharge from Residential s w s w 4 22 000 Transfer to Outside Facility s w s w 4 22 3811s s s w ws s w s s s Outpatient Treatment s w s s w w 6 33

000 Referral to Inpatient s w w w 4 13

000 Referral to Residential s w w w 4 13

011 s W alk-in to Outpatient s w s w 4 22

000 Purchasing (Supplies &

Services) s s w s 4 31 000 Patient Data Managements w s s w w s s s 9 63 000 Research w w w w s s s s s w 1055 000 Facilities and Maintance s s s s s sw w w s 1073 000 Quality Assurance s s w w s s w w s 9 54 000 Payroll s w w w s 5 23 000 Human Resources s w s s s s w 7 52 1 1 1 1 1 1 1 1 4 1 1 1 1 9 16 15 7 1 3 3 2 9 21 3 3 3 21 2 3 1 1 1 1 0 0 1 0 4 0 1 1 1 7 9 5 5 1 1 3 2 5 110 1 1 4 2 1 0 0 0 0 1 1 0 1 0 1 0 0 0 2 7 10 2 0 2 0 0 4 1 3 2 2 17 0 2

2

1

1

1

4

4

2

2

2

1

3

1

1

2

2

3

1

5

5

6

4

3

0

1

5

3

0

2

1

3

2

3

1

1

0

1

7

7

5

4

4

5

7

5

2

3

4

4

3

5

3

4

1

6

s

s

s

w

w

w

w

s

w

w

w

w

s

13

5

8

s

s

s

s

w

s

w

s

w

s

s

w

12

8

4

s

s

s

s

w

w

w

w

8

4

4

w

s

w

w

w

5

1

4

s

s

s

s

w

s

s

w

s

s

s

w

w

13

9

4

w

w

s

s

s

s

w

s

s

s

s

w

w

13

8

5

s

s

w

s

w

w

s

s

w

w

s

w

w

w

w

15

6

9

Serve Boston Healthcare System

Team Oriented - Integrated Care

Quality Improvement

Complience -VA Code of Patient

Concern & JCAHO

Evidence Based Care (inc. Through

Educational Residencies)

Become World Class Research

Hospital

Accessible Care

U

ps

tandi

ng m

em

ber

of l

oc

al

c

om

m

uni

ty

C

or

rec

tnes

s

of di

agnos

is

and

tr

eatm

ent

Ti

m

el

ines

s

of di

agnos

is

and

tr

eatm

ent

R

es

ear

c

h A

dv

anc

em

ent

K

now

ledge Tr

ans

fer

Q

ual

ity

of pati

ent ex

per

ienc

e

(m

ini

m

al

di

s

c

om

for

t, r

es

pec

tful

, etc

.)

Ti

m

el

y

and ac

c

ur

ate i

nfor

m

ati

on fl

ow

S

afety

/S

ec

ur

ity

of pr

em

is

es

C

lean, H

igh Q

ual

ity

Fac

ili

ty

R

eas

onabl

e ex

pec

tati

ons

and

res

pec

tful

tr

eatm

ent of em

pl

oy

ees

C

om

m

uni

c

ati

on and Im

pl

em

entati

on

of V

A

c

ul

tur

e and v

al

ues

E

ffi

c

ient R

es

our

c

e M

anagem

ent

A

c

c

ur

ate and w

el

l-doc

um

ented

m

onetar

y

tr

ans

ac

ti

ons

O

per

ati

ng w

ithi

n budget

Fai

r Wages

for

s

er

v

ic

es

S

uffi

c

ient Inpati

ent and O

utpati

ent

C

apac

ity

A

c

c

ur

ate P

ati

ent R

ec

or

ds

A

v

ai

labi

lity

of m

edi

c

ati

ons

, s

uppl

ies

,

and equi

pm

ent

Metrics

Stakeholder

Values

Key Processes

Strategic

Objectives

Metrics

Stakeholder

Values

Key Processes

Strategic

Objectives

(16)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

16

Patients

Homeless Shelters

Doctors

Pharmacy

Hospital Management

Employees

VA Leadership

Universities & Residents

Community

Politicians

Finance

Volunteers

Patients

Supply Chain

Partner Hospitals

Tax Payers

High

Low

High

E

n

ter

p

ri

se

V

a

lu

e

D

el

iv

er

y

t

o

S

ta

ke

h

o

ld

er

Stakeholder Relative Importance to Enterprise

Stakeholder Value Comparison

X-Matrix Version

Methodology

Inferred Stakeholder Importance from Strategic Objects & Value Delivery from the

Key Processes

Used weighting algorithm to calculate positions

More research & data needed on weights, and to validate results.

Doctors

Pharmacy

Hospital Management

Employees

Universities & Residents

Community

Tax Payers

Finance

Volunteers

Partner Hospitals

VA Leadership

Politicians

Supply Chain

(17)

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© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

17

LESAT Gap Analysis

LESAT Section Level X.X

Current State and Gap

0

1

2

3

4

5

I.A

I.B

I.C

I.D

I.E

I.F

I.G

II.A

II.B

II.C

II.D

II.E

II.F

III.A

III.B

LESAT Section X.X

A

ver

ag

e L

E

S

A

T

P

ract

ice M

at

u

ri

ty i

n

S

e

c

tio

n

X

.X

Gap

Current State

Life Cycle Processes

High Scores

Developing product & process

Producing the product

Low Scores

Business acquisition and

program management

Business acquisition and

program management

High Scores

Developing product & process

Producing the product

Low Scores

Business acquisition and

program management

Business acquisition and

program management

Enabling Infrastructure

Equal Scores

Lean organizational enablers

Lean process enablers

Equal Scores

Lean organizational enablers

Lean process enablers

High interest in Lean

Low Lean awareness

Lean Transformation Leadership

Highest Scores

Developing Lean structure and

behavior

Adopting Lean paradigm & value

stream focus

Lowest Scores

Creating & implementing Lean

initiatives plan

Enterprise strategic planning

Highest Scores

Developing Lean structure and

behavior

Adopting Lean paradigm & value

stream focus

Lowest Scores

Creating & implementing Lean

initiatives plan

Enterprise strategic planning

LESAT Section Level X.X

Current State and Gap

0

1

2

3

4

5

I.A

I.B

I.C

I.D

I.E

I.F

I.G

II.A

II.B

II.C

II.D

II.E

II.F

III.A

III.B

LESAT Section X.X

A

ver

ag

e L

E

S

A

T

P

ract

ice M

at

u

ri

ty i

n

S

e

c

tio

n

X

.X

Gap

Current State

Life Cycle Processes

High Scores

Developing product & process

Producing the product

Low Scores

Business acquisition and

program management

Business acquisition and

program management

High Scores

Developing product & process

Producing the product

Low Scores

Business acquisition and

program management

Business acquisition and

program management

Enabling Infrastructure

Equal Scores

Lean organizational enablers

Lean process enablers

Equal Scores

Lean organizational enablers

Lean process enablers

High interest in Lean

Low Lean awareness

High interest in Lean

Low Lean awareness

Lean Transformation Leadership

Highest Scores

Developing Lean structure and

behavior

Adopting Lean paradigm & value

stream focus

Lowest Scores

Creating & implementing Lean

initiatives plan

Enterprise strategic planning

Highest Scores

Developing Lean structure and

behavior

Adopting Lean paradigm & value

stream focus

Lowest Scores

Creating & implementing Lean

initiatives plan

(18)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

18

Enterprise Processes

Emergency Services

VA Urgent Care Transfer

VA ER Transfer

Non-VA ER Transfer

Inpatient Treatment

Chronic Care

Acute Care

Residential Programs

Substance Abuse

PTSD

General Mental Health

Women

Community Residential

Domiciliary

Bedford Stabilization

Program

Enabling Infrastructure

Purchasing

Patient Data Mgmt

Research

Quality Assurance

Payroll

Human Resources

Outpatient Treatment

Treatment

Scheduling

Non-Emergency

Walk-In to Outpatient

Referral from Primary Care

Outpatient Clinics

West Roxbury

Jamaica Plain

(19)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

19

Supplier

Emergency and non-emergency hospitals sending ineligible veterans

to Mental Health

Information Flow

Little accesses to patient records from the Department of Defense

Lack of documentation from transfers and referrals

Processes

Long wait times in admitting, transferring, and discharging processes

Need more knowledge sharing among programs and departments

People

Need to spread knowledge of service lines among staff and overcome

training siloing

Opportunity for improvement with patient teams

Infrastructure

Inefficiencies in resources by providing treatments at multiple sites

Transportation waste: moving people among sites

(20)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

20

Enterprise Waste

Leadership

Strategic goal and objectives are not published

Strategic goals not fully aligned among parent-child enterprises

Inadequate communication channels between VA New England and

VA Boston Mental Health Services and between VA BMHS and VA

BHS

Customer

Veterans

Patient opting not to conform to treatment and developing

dependency on system for support and shelter

Multiple visits for complete evaluation

Commuting home to site and site to site

Resource limitations with beds and program capacity

Physicians

Redundant testing from patients who are referred from the military

and other institutions

Resource limitations with beds and program capacity

Commuting home to site and site to site

(21)

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© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

21

(22)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

22

Team:

Oladapo Bakare

Jordan Peck

Orietta Verdugo

Veteran Affairs

Boston Mental Health

Enterprise Architecting

May 13, 2009

(23)

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© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

23

Agenda

Current Architecture

Enterprise Vision

Candidate Architectures

Architecture Evaluation

Transformation Plan

(24)

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© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

24

(25)

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© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

25

(26)

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© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

26

View Interrelations

26

Policy / External Factors

Process

Organization

Strategy

IT/Infrastructure

A

Products /

Services

Knowledge

Lacks strategy within the organization,

only top levels have input to strategy.

Needs more integrated understanding of

the process flow; Build artifacts of

standard processes and documentation

across all sites

Main focus of the enterprise as its mission

is servicing the veterans and their needs

Main driver of business strategy and services;

Government and policy driven; Public

Relations plays a factor as well.

Clear knowledge exchange is

needed; Meetings and emails are

primarily communications; Not

enough knowledge sharing between

leadership within VISN

Lacks clear organizational direction from leadership; Needs

an employee feedback loop and more collaboration between

sites, departments, and networks

IT system that links VA documentation and procedures across the

enterprise (IT ahead in national health care); Infrastructure has

various locations

(27)

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© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

27

Scalability

Accessibility

Responsiveness

Quality

Safety

Serviceability

Customizability

Demonstrability

The Ilities

Survivability

Ability for a system to

readily expand capacity

Ability to reduce defect

& optimize service

Veteran’s ability to access

& afford services

Ability to quickly respond

to changes or needs in the

system

Ability to reduce defect

& optimize service

Ability to adapt to changes

& process requirements

Meeting VA national &

accreditation board

requirements

Ability to measure

performance

Ability to treat a

patient based on their

particular needs

Ability to treat a

patient based on their

particular needs

Ensure wellbeing of

patient & employees

(28)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

28

(29)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

29

• Strategy driven by all levels of the organization, through continuous

improvement methods

• Create and maintain strategy document that delineates the actionable strategic

goals at all levels of the organization

• Increase strategy visibility and awareness through meetings between

professionals

Integrate understanding of the process flow through standard processes and

documentation across all sites

Obtain process measurements that directly align to strategic goals

Transparency throughout the organization of processes and performance

Continuous process improvement; Yearly goal to meet, incentivizing

improvements, educate and give resources for improvement.

Strategic View

Process View

(30)

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© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

30

Clear organizational direction from leadership on all levels to proactively push

agendas

Increase collaboration between sites, departments, and networks

Incentivize employees to take ownership of patient services

Create an employee feedback loop to communicate needs, best practices, and

change

Lean Six Sigma department throughout VA to drive quality and continuous

improvement initiatives

Clear knowledge exchange between employees, programs, and sites

Incorporate knowledge exchange programs with other VA campuses to share

best practices

Increase leadership communication amongst VISN, departments, and

networks

Organizational View

Knowledge View

(31)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

31

Future Vision

Upgrades given to all sites within the same time frame

Ensuring there is a sufficient IT budget each year

Making sure practitioners are able to make changes to the system to facility

processes/procedures

Ability to communicate efficiently with all campuses

Proficiency and acceptance from all staff

Expansion of utility to customers to reduce costs from excess or forgotten

appointments

Making sure practitioners are able to make changes to the system to facility Being

active in driving policy and program initiatives

Increase agility in responding to policy changes

Ability to buffer themselves from extreme political changes

Understand the needs and expectations of veterans, families, and community

IT View

(32)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

32

Future Vision

Improve service efficiency

Expand services to fit all incoming customer needs

Measure services more carefully

Re-design services for continuum of care approach

Insulate services from outside factors

Make service offerings clearer to potential patients

Integrate services and improve ability to customize based on patient

Service/Product View

(33)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

33

(34)

http://lean.mit.edu

© 2009 Massachusetts Institute of Technology /VA Mental Health /Peck 06/03/09

34

Candidate Architectures

Illness Based

Pros:

Continuous care in a given category can be easily tracked and

traced

Flexible if new mental disorders, programs, or illnesses arise in the

future

Cons:

Many patients fall into more than one category

Wasted resources on programs that have low volume or excess

capacity

Homeless Prog.

Homeless Prog.

Serious MI

Serious MI

Vocational

Residential

Inpatient

Outpatient

Sexual Abuse

Sexual Abuse

Vocational

Residential

Inpatient

Outpatient

TBI

TBI

Vocational

Residential

Inpatient

Outpatient

PTSD & SA

PTSD & SA

Vocational

Residential

Inpatient

Outpatient

Vocational

Residential

Outpatient

Homeless Prog.

Homeless Prog.

Homeless Prog.

Homeless Prog.

Homeless Prog.

Homeless Prog.

Homeless Prog.

Homeless Prog.

Serious MI

Serious MI

Vocational

Residential

Inpatient

Outpatient

Serious MI

Serious MI

Serious MI

Serious MI

Serious MI

Serious MI

Serious MI

Serious MI

Vocational

Residential

Inpatient

Outpatient

Sexual Abuse

Sexual Abuse

Vocational

Residential

Inpatient

Outpatient

Sexual Abuse

Sexual Abuse

Sexual Abuse

Sexual Abuse

Sexual Abuse

Sexual Abuse

Sexual Abuse

Sexual Abuse

Vocational

Residential

Inpatient

Outpatient

TBI

TBI

Vocational

Residential

Inpatient

Outpatient

TBI

TBI

TBI

TBI

TBI

TBI

TBI

TBI

Vocational

Residential

Inpatient

Outpatient

PTSD & SA

PTSD & SA

PTSD & SA

PTSD & SA

PTSD & SA

PTSD & SA

PTSD & SA

PTSD & SA

Vocational

Residential

Inpatient

Outpatient

Vocational

Residential

Outpatient

Short Term

Short Term

Urgent Care

Inpatient

Outpatient

Intermittent

Intermittent

SAARP

WITRP

Long Term

Long Term

PATH

RISE

REACH

LT Stay

Private Homes

Programs

Programs

Homeless

CWP

Short Term

Short Term

Urgent Care

Inpatient

Outpatient

Intermittent

Intermittent

SAARP

WITRP

Long Term

Long Term

PATH

RISE

REACH

LT Stay

Private Homes

Programs

Programs

Homeless

CWP

Patient Length of Stay

Pros:

Resources can be maximized through each department

Cons:

Unbalanced system with excess capacity in some units and

overflow in others

Patients currently transition between some or all of the programs

Metrics will be focused on local maximization rather than

focusing on optimal flow across the organization

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Investigar los cambios en los valores de la osmolalidad urinaria y las fracciones de excreción de sodio, potasio, cloro y magnesio, al momento del diagnóstico y

Les principaux avantages du tracé Nord modifié se manifesteront par une réduction des niveaux sonores dans la municipalité de Saint-Bruno puisqu'il aura pour effet de diminuer de

Effectuer un inventaire archéologique portant sur les sites préhistoriques et historiques amérindiens et historiques eurogènes impliquant une inspection visuelle systématique et

De plus, selon l’article 119 de notre constitution, il est interdit de fusionner du matériel génétique non humain avec le patrimoine humain : «le pa- trimoine génétique et