QUALITY AND PERFORMANCE MEASUREMENT IMPROVEMENT AND INCENTIVES IN HEALTHCARE
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Dr. Lynn is a DBH and a relatively new member of the Patient-Centered Medical Home team in a busy, but small urban primary care clinic. Dr. Lynn has been working in the clinic for 9 months as the first and only Behavioral Health Consultant. She took great care to establish herself with the team. From the office administrator to the four PCP’s, four nurses and the nutritionist. Dr Lynn educated the team about the importance of integrated behavioral health and demonstrated the value of the hallway hand-off. Over the past few months the team gained increased understanding, confidence and interest in referring patients with appropriate problems – poor medication adherence, difficulty making and maintaining changes in nutrition and physical activity, depression and anxiety co-morbid with medical disease.

Dr. Lynn wanted to take it to the next level. She wanted to put into practice the lessons learned in her DBH program and implement a population health management program. She decided to implement a combined depression and substance use disorder screening program using the PHQ-9 and the AUDIT. Further, she would use the new reimbursement codes for both SBIRT screening and for patients at high risk, the new chronic disease care management codes. Dr. Lynn decided that she would start a new stress management group for depressed patients. Patients who met criteria for “sub-threshold” depression as well as DSM-V depression would meet criteria for assessment and treatment. She would also start an education and behavior change group for substance use disorder for patients with mild to moderate severity substance abuse based on the AUDIT. Consistent with the SBIRT model she would refer patients with severe substance abuse to a local specialty substance abuse clinic. After patients were stabilized she planned to conduct telephonic follow-up and educate patients on the use of internet and smart phone APP behavior change resources.

Dr. Lynn spent several months planning this new population health management program. She was excited about the opportunity to achieve the triple aim. By identifying and treating patients she would improve the patient experience of care. By using a population health management program she would improve the population of the entire clinic population of at-risk depressed and substance abuse patients in the clinic. She knew that these patients had higher utilization and associated costs and was confident that with appropriate treatment clinical outcomes would improve, hospital and ED utilization would decrease and she would achieve the goal of Return on Investment. Dr. Lynn made a series of great presentations to the clinic leadership, clinical team and administrative staff. She sold the package and sealed the deal.

The new program was launched on a Monday. By Wednesday, there was chaos in the clinic! The screens were administered and automatically scored on the clinic ipad at patient check-in with the help of the office assistant. The PCP’s and nurses reviewed the results of the screen and made the hallway hand-off to Dr. Lynn. So far, so good, things were going swimmingly. However…it turns out that about 25% of all patients each day were screening positive based on the cut-off scores. Between the 4 PCP’s who saw an average of 25 patients per day, a total of 25 patients were being referred to Dr. Lynn. By luck of the draw, many of the patients were identified around the same time, so Dr. Lynn was faced with each of the PCP’s approaching her for a warm hand-off only to find that she already had 1 patient in her office and 1-2 more in the waiting room.

Dr. Lynn was overwhelmed. She had planned to use the 5 A’s model to engage and develop treatment plans with patients using a brief intervention model that required 30 minutes. She did not plan on a backlog of patients in the waiting room and not enough time in the day to see all of them. The office administrator started to notice grumpy faces on patients waiting and was soon fielding questions and complaints from waiting patients. The PCP’s were getting annoyed that the hallway hand-off model that worked so well up to this point suddenly seemed broken and led to frustration. The nurses were empathic and wanted to help but really had not significant training or experience in brief interventions for depression or substance abuse.

Exasperated, Dr. Lynn pulled the plug on the program by Friday morning. The team was relieved and felt bad that the program didn’t work, and they still had confidence in Dr. Lynn for doing the same type of work she had been doing before the new program. Dr. Lynn was disappointed, frustrated…and tired! But she was trained in quality improvement and Lean, and she was determined to both evaluate what went wrong AND how to re-launch the program but with modifications based on the lessons learned.

For your discussion board, discuss what you would do to re-launch a population health management program after this episode of chaos in the clinic. What would you do differently? How would the population health management program be changed to avoid the chaos? How would you re-engage the team and get them to give you a second chance? What quality improvement or Lean strategies and techniques might you utilize in order to better plan the program?

 

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QI Assignment 1: Complete a Value Stream Map

Instructions:

Read Chapter 3 in Delisle carefully “Principle 2: Map the Value Stream”. I note specific pages from these readings in the instructions below to assist you with each section of this assignment.

In this assignment complete the following steps:

Identify a healthcare process. See the example in :”Chapter 3 Principle 2: Map the Value Stream” (see attachment in Week 3). The process can include a patient, such as the example of a patient visit for a PCP exam. Or, it may include a process that does not involve a patient, such as a process for completing lab work. Ideally, you will select a process that you can observe in your current place of employment. If you are not employed, think of a past job you had and an example of a process in that setting.

If you have no experience working in healthcare, then you can use the fictional case study “Case Study with data for Assignment 1: Value Stream Map for Dr. Lynn’s clinic” below. This case study is based on the example of a patient who makes a visit for a PCP exam and then is referred to a Behavioral Health Consultant (BHC) for a “warm handoff” (meaning the physician walks the patient to the BHC in a clinic exam room, introduces patient to the BHC, and leaves the patient with the BHC for an evaluation).

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 weekJ. She works in a busy urban primary care clinic staffed by an administrative assistant, a scheduler, four PCP’s, 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 BHC (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 includes 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 minutes (FPY: 97%). The patient then waits in the waiting room for 14 minutes. Then the patient is called in to compete vitals with the PA, that takes 5 minutes (FPY: 95%). The patient returns to the waiting room and waits an average of 12 minutes. Then the patient is called into the examination room for the nurse interview. The nurse interview takes 4 minutes (FPY: 90%). Then the patient waits in the examination room for an average of 17 minutes until the PCP arrives for the PCP examination. The PCP examination takes 12 minutes (FPY: 90%). The PCP then walked the patient to Dr. Lynn’s examination room and introduced the patient to Dr. Lynn. This takes 2 minutes. Dr. Lynn then completes the BHC interview that takes an average of 20 minutes (FPY: 85%). Upon completion of the BHC 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 one minute.

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.
•BHC interview.
•Check-out.

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 re-administered 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 PCP’s 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 PCP’s 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 if the referral. Dr. Lynn identified the need for improved patient information on her service and perhaps a script for PCP’s 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 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.

Complete a Value Stream Map. Begin with a process map of the current state (see pages 33-35). The current state is the process as it currently stands; what actually takes place, not what should take place. The map should include a high-level process map and a midlevel process map. Include the time spent waiting in between steps in the process map.

TIPs for completing a Value Stream Map

Lucidcharts is the recommended software for completing the Value Stream Mapy. You may also useMicrosoft Word or Powerpoint: Go the to the “SmartArt” tab and select “Process”. Experiment creating the high-level and mid-level by adding process steps for SmartArt. Open the “text panel” to add more steps in the process. Experiment with using this tool.

Estimate the cycle time needed to complete each step in the process map. Cycle time is the time needed to complete a specific process step. See Figure 3.7 on page 36.

Calculate a First-Pass Yield (FPY) for each step in the process and the overall process FPY yield. See page 37. The FPY is simply an estimate of the percentage of time that a process step is performed correctly the first time. Examples: Checking in with the receptionist, completing a PHQ-9 depression screen, having vital signs taken. The overall FPY is calculated by multiplying each individual step FPY (see Figure 3.8 page 37).

Evaluate Value Added (VA) versus Non-Value Added (NVA) activity for each process step. Carefully read the section “Identify Waste” in Delisle “Executing Lean Improvements” Chapter 2 pages 17-27 . Identify 3 key categories of VA and NVA based on the definitions in this section:

1. “VA activities” = activities that performed during the production or delivery of the service that increase it’s value to the customer.

2. “NVA required” = NVA activities performed during the production or delivery of a service that use time and resources but do not increase value to the customer, but are required due to legal, regulatory, accreditation or other requirements.

3. “Waste” = NVA activities performed during the production or delivery of a service that use time and resources but does not increase value to the customer and is not required for legal, regulatory, accreditation or other reasons.

a. There are 8 types of Waste using the mnemonic DOWNTIME (see pages 17-27 in Delisle)

i. Defects

ii. Overproduction

iii. Waiting

iv. Not utilizing peoples abilities

v. Transportation

vi. Inventory

vii. Motion

viii. Excess processing

Complete VSM Calculations (See box on top of page 44)

1. Cycle time

2. Wait time

3. Lead time

4. Value-adding ratio (VA time)/(Lead time)

5. First-pass yield: multiple every process step FPY

Identify opportunities for improvement based on the FPY and NVA activities. This section of the assignment should be a written narrative summary. Use the “Case Study” example on page 57 in Delisle as an example. Simply describe what process improvements you have identified based on the VSM that can improve cycle time and decrease waste. Do include the VSM steps and calculations to identify problem areas and propose solutions in this narrative. Be brief and do not go into excessive detail on your plan for improvement. A more detailed plan will be required in QI Assignment #2 in this class when you complete a PDSA. This written narrative should be 1 – 2 pages in length. Use APA Style and good grammar for narrative sections. References are not required for this narrative. However, if you would like to add a relevant reference you may do so.

Value Stream Map Delisle Executing Lean Ch .pdf
.

2. Assignment

 

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Cost Accounting
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1. A company’s margin of safety is defined by the sales volume and dollars which exceed its breakeven point. The degree of operating leverage is defined by the contribution margin divided by operating income. For this discussion:
•How might the calculation of the margin of safety be used for decision-making during a period of economic downturn?
•How might the degree of operating leverage be used for decision-making during a period of economic downturn?

2. Watch the Jelly Belly Candy Company Virtual Plant Tour at the link provided in Module 3. After watching the series of videos, respond to the following:
1.For the various flavors of products, would the company be more likely to use job or process costing? Rationalize your response.
2.For the basis of overhead allocation, would the company be more likely to use a machine- or labor-based driver? Rationalize your response.
3.Assume that overhead is under allocated by 6% for the period. Would the company be more likely to expense or capitalize this adjustment?

3. Rick White has recently discussed the intent to diversify Swiss Chocolate’s product line with Steve Smith. Smith notes that the new product will be a dark chocolate candy bar featuring various types of dried fruit and a higher percentage of cacao, which will be touted as a heart-healthy product due to high antioxidant nutritional qualities. This differs from the current basic milk-chocolate bar that Swiss Chocolate manufactures presently, which has no added fruit. White has related the fact that the company expects this coming year’s milk-chocolate bar volume to decline and the new product volume to rise. There will be a new machine required to accommodate the new product, and it will run in batches.

White suggests that Smith consider Activity-Based Costing for completing this analysis. Before Smith undertakes this analysis, he considers the advantages and disadvantages of implementing activity-based costing.
•Indicate an advantage to implementing ABC for this scenario. Support your response.
•Indicate a disadvantage to implementing ABC for this scenario. Support your response.

4. The US division of Swiss Chocolate has a budget directive to achieve a specific level of operating income for the period. If the specific level of operating income is achieved, the plant manager, Rick White, will receive a bonus.

White communicated the requirements to management and requested that the managers estimate their departmental costs and submit to Smith for compilation of the operating budget for the period.

When the projected budget costs were compiled, Smith noted that management’s estimates of costs were less than anticipated, which resulted in a higher anticipated level of operating income than the target established by the Swiss home office. White was informed of this, and made a suggestion to increase costs within the budget in order to provide a “buffer” in case an unexpected event occurred resulting in greater spending. Smith was greatly concerned with White’s request. Rick indicated that this was just his suggested approach to “risk management.”
•What type of practice is Rick suggesting?
•What are the ethical implications for Steve in this situation?
•What would you suggest Steve do to solve this dilemma?

5. During the month of September (the last month of Swiss Chocolate’s fiscal year), Steve Smith calculated the production volume variance for the month, noting a significant favorable variance resulting from increased production. In fact, despite the lack of change in the sales forecast for the entire year, production had increased 20% for the month. Smith was concerned with the outcome and requested a meeting with Rick White, the plant manager.

White indicated that indeed, he had directed the production department to increase manufacturing for the period. Although White indicated that the rationalization for increased production was the approach of the holiday season and increased orders which would be shipping soon, Smith was concerned that he had another motive.
•What was the effect of the production volume variance on plant operating income?
•If White’s bonus is based on operating income, what concerns should Smith have at this point?
•Were White’s directives justified?

6. Steve Smith has completed an evaluation of the effects of a favorable production volume variance from the prior period. He proposes to Roberta Blake that the use of a variable costing income statement rather than an absorption costing income statement for the basis calculating incentive rewards would encourage more ethical behavior, when rewards are based on operating income.
•Do you agree with Smith’s suggestion?
•Are there any reporting considerations which impact the preparation of a variable costing income statement?
•If Blake and Smith agree that only absorption costing is appropriate, are there any methods to fairly capture the effect of increased inventories during times of overproduction?

7. Many equipment replacement or outsourcing decisions have relevant qualitative considerations which may impact the acceptance of a quantitative evaluation, regardless of the calculated outcome. For instance, Steve Smith has completed an analysis of budgeted volumes for the US division of Swiss Chocolate Company for the coming year, and noted that the firm’s direct labor cost of production is significantly less per unit than its Swiss affiliate plant, but is higher than its Mexican affiliate plant. The Swiss corporate office has indicated that if its costs are not competitive with the Mexican plant, closure of the US plant is imminent.

Rick White has proposed a plan for automation of some of the processes which are now completed by hand at the US division. Although the expected results are attractive, five of ten or half of the production staff would be terminated.

Consider the ethical implications of such a decision. Would the replacement of the equipment be optimal? What might the impacts be to the workforce? Would there be potential impacts on financial results which extend beyond the immediate savings proposed in the equipment replacement?

 

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Expression of Ideas; APA Style

Elaborated on ideas of others including instructor and classmates by sharing additional examples and adding further explanation; Discussion was expressed in a clear and respectful manner; APA style adhered to; no spelling or grammar errors; is within word limits.

Postings were constructive but lacking clarity; Posting done in a respectful manner; Moderate problems with APA style noted; minimal problems with spelling or grammar; exceeds word limits.

Minimal follow-up on others’ ideas; Ideas expressed unclear; Posting was expressed in a respectful manner; Major problems with APA style evident; moderate problems with spelling or grammar; exceeds word limits.

20 & 20

/20

/20

Total Score

DIABETIC NEPHROPATHY

OVERVIEW

Diabetes is an insidious disease process which slowly touches all parts of the patient’s life. One of the major areas is that of the kidneys. Diabetic nephropathy is the leading cause of chronic kidney disease in the United States (Batuman, 2014). Other terms related to this medical problem are diabetic glomerulosclerosis, intercapillary glomerulonephritis, and Kimmelstiel-Wilson disease (Wisse, 2013).

DIRECTIONS:

Choose at least three (3) of the related topics below to discuss in full detail. If three (3) topics are not enough to give you 300 words for your primary discussion, select a fourth (4th). When responding to a classmate, do “NOT” select someone who wrote on the same topics as you did. This will give you the opportunity to grow.

Topics to choose from for discussion:

Screening Lab tests

Disease development Treatment

Diagnostic criteria Signs & Symptoms

Potential long term complications Comorbidities

Nutrition Prevention

Social implications Prognosis

 

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