For more information, go to http://neenan.com or call 970.493.8747 As presented on March 19, 2010 at the 2010 AMGA Annual Conference Presented by: Randall Huss, M.D., President, and Gerald Dowdy, VP Operations, St. John’s Clinic – Rolla Division; and Miguel Burbano de Lara, AIA, NCARB, Senior VP Healthcare, The Neenan Company When faced with the opportunity of designing a new ambulatory facility to house a multi-specialty clinic practice, ASC and other outpatient services to be completed a year after implementation of their EHR, the St. John’s Clinic-Rolla team partnered with a progressive architectural team, The Neenan Company, to design and build a facility around the new electronic workflows. They integrated Lean workflow redesign and Lean facility design elements to achieve a facility capable of supporting the digital, paperless ambulatory practice of the future.

1. ST. JOHN’S CLINIC Rolla, Mo ST. JOHN’S CLINIC Rolla, Mo

2. Ambulatory Health Care Facility of the Future:Integrating Lean Workflow Redesign and Lean Facility Design Principles Randall Huss, MD, President Gerald Dowdy, VP Operations St. John’s Clinic-Rolla Division Miguel Burbano, VP for Health Care The Neenan Company

3. What if . . . ? What If . . . Standard exam rooms Greeting lobby with kiosk check-In Immediateaccess to information Servicesbrought to patient Patient-centered comfort Leverage capabilities of robust EHR Fully digitalservices Quietoffice Teams of physicians and nurses Improved communication Sharedphysician lounges

4. At lesscost! Moreproviders Morepoints of care Moreservices Morerevenue per square foot per provider . . . . In 14 months or less

5. Opportunity And Challenge

7. What if . . . ? The Future Do more with same or less Baby boomers surge Integrated, coordinated care Team-based care Leverage technology Chronic disease management Multiple access points Transparency and accountability

8. Charge to Architects: Ambulatory Facility of the Future

9. Strong, clear vision Embrace economic challenges Physician buy-in Leadershipsupport Teamapproach Workflow redesign Critical Success Factors

10. Lean Principles What if . . . ? Lean Principles Remove waste - eliminate non-value added work Pursue perfection - zero defects Workplace organizationandstandardization “Just in time”inventory Single piece flow; eliminatebatching “Pull” vs. “push” Continued pursuit of improvement

11. US health care costs highest in the world It is the access point to health care Less technologicallycomplex; more logisticallycomplex (compared to inpatient care) The Mandate to Transform Ambulatory Care

12. Obsolete Practices The Mandate to Transform Ambulatory Care Typical office workflow & designhave changed little in the last 50 years American Ambulatory Care is still a cottage industry, uncoordinated and unaccountable

13. Why transform Ambulatory Care?

14. Greater opportunity to improve health of population Frontline for preventive health care / wellness Increase patient safety Demand for patient–centered care Patient–Centered Medical Home initiative

15. Manage Lean Principles What if . . . ? New Model of Care Over 65population will double by 2030 Health care must support the increased demand

16. Lean Principles What if . . . ? New Model of Care Team-based care Multiple points of access Interactivetechnology Chronic caremodel Telemedicine and e-visits Patient-Centered Medical Home

17. Patient-centriccare Leverage capabilities of robust EHR Avoid paving the “cow paths” Why Redesign Workflows?

18. Lean Principles What if . . . ? “It’s About Time . . .” “The Patient-Centered, Physician Efficient Visit” To focus on the patient’s experienceand expectations To enhance the efficiencyand effectiveness of the physician

19. Site visits University of Utah Community Clinics “Learning Days” Frequent provider meetings presenting Lean design opportunities Earlyexecutive decision for call center Getting Started

20. Physician & Co-Worker Off-Site Retreat Getting Started Utah Leadership presented experience St. John’s OPI Lean Team led group exercises Physicians and co-workers challenged to apply workflow changes priorto Epic implementation

21. Focus on patient experience Right person / right job Standardization Lean facility design Leverage and exploit technology Effective communication Core Principles

22. Lean Clinic Workflow Redesign

23. Manage Lean Principles What if . . . ? The Patient Centered Physician Efficient Visit The Goals Analysis of Ambulatory office visit process from patient’s perspective Optimize physician time and satisfaction

24. Manage Lean Principles What if . . . ? The Patient-Centered Physician Efficient Visit Eliminate steps; avoid provider leaving the room Eliminate all waste including non-value added work Minimize patient movement Standard workflows,room layout and supplies Lean Process Improvement

25. Manage Lean Principles What if . . . ? The Patient-Centered Physician Efficient Visit Implementation Strategies Call center: centralized scheduling, registration, nurse triage, medication refills, Epic messaging Monitor and manage call center metrics Advanced access scheduling, minimal rules Ultimately patient self-scheduling (Epic “My Chart”)

26. Manage Lean Principles What if . . . ? The Patient Centered Physician – Efficient Visit Implementation Strategies In-room scheduling and check-out Patient has future appointments before leaving exam room The Care Team model

27. Manage The Care Team Model LPNs/MAs trained to advanced competencies Participate In Epic documentation Off-load physician tasks LPNs/MAs work as team; not assigned to one provider

28. Manage The Care Team Model Up-staffLPNs/MAs per provider Provider and LPNs/MAs co-located Only caregiversin the suite

29. Manage The Care Team Model

30. Manage Facility Design Considerations Lean principles Design for EHR workflows Reception/check-in “kiosk” design Minimize lobby area (“waiting” room) Galleria concept for visitor comfort

31. Manage Facility Design Considerations Care Team core located centrally in suite Receptionist, check-out, and chart storage areas eliminated Flexible interconnected business unit modules with “swing rooms” Significantly reduced storage – Just in Time inventory

32. Manage Facility Design Considerations Optimized space efficiencies within offices Shared physician lounges over physician offices Standard rooms; not assigned to only one provider Allow minimum 3 rooms/provider in clinic

33. Manage Facility Design Considerations Telemedicine room on each floor Digital radiography with PACS; no wet processing Pharmacy with drive-up C.O.W. (“Calf”) and printer in each room Community room doubles as group visit room

34. Engagement, participation andcollaboration Led to acceptanceof Lean principles Financial analysis of Lean design alternatives Sealing the Deal

35. SPACE – 13% Reduction CAPACITY – 16% Increase Lean Facility Design Results

36. SPACE – 20% Reduction CAPACITY – 16% Increase Lean Facility Design Results

37. Financial Savings Lean Facility Design Results Construction Cost $3,891,500 Annual Occupancy Cost $498,112 Annual Operation Cost $110,000 +/-

38. Occupancy Cost Lean Facility Design Results Reduction in allocated occupancy cost to physicians 800-900 vs. 1300-1500 sq. ft. / physician

39. Model for the Future Model For future Ambulatory Care & facility design for St. John’s Clinic and Mercy Health System Regional and national interest

40. Operational Deployment and Challenges

41. Manage Operational Challenges Epic EHR Go Live October 2008 Occupy new facility in September 2009 Fully Functioning EHR thus No Paper Charts Implementation of Lean Design and Philosophy Care Team Model Call Center Economic downturn

42. Manage Operational Challenges Widespread support for the EHR General agreement with Lean principles Resistance to change focused on the Care Team model and call center

43. Manage Preparation Project team had multiple visits to University of Utah Community Clinics - “Learning Days” Program Embrace skeptic thought and clinic leader Attended additional educational seminars for Lean Leadership attended Lean training Pre Epic “Go Live” retreat

44. Manage Preparation / Call Center Physician survey regarding expectations Physician Champion One on One physician meetings Physician appointment schedule template Protocol development Scripting

46. Processes

47. Communication

48. Standardization

49. Just in Time InventorySelf-identified units added each week

50. Manage Critical Success Factors Passionately follow the vision Make data driven decisions Plan and design for the regular 90% and manage to the 10% exceptions Significantly reduce or eliminate appointment rules

52. Patient triaging

53. Test reporting / communicatingWhen resistance occurs, ask why five times Willingness to accept incremental improvement

54. Manage Overcoming Resistance Lean Implementation Improved efficiency Lowertotal costs Bestpractices Communication Physician champions

55. Manage Overcoming Resistance The Care Team Better overall care More patient-centered A team of “best” nurses rather “your” nurse EHR enables Care Team model Communication Physician champion

56. Manage Overcoming Resistance The Call Center Allow clinical area to focus on care of the patient Redesign the receptionist position Key component of the Care Team concept Noise reduction – minimal phone disruption Expanded and consistentphone coverage

57. Manage Overcoming Resistance The Call Center Best practices model Communication Call center metrics Physician champions and executive decision

59. Manage Lessons Learned Call Center Unknown call volume Schedulers vs. nursing staff Staffing model for demand Staff selection and competency New digital technology – new processes Educating patients “Call Center” label

60. Design and FacilityImplementation

61. Manage The Magnitude of Change How BIG is it ?

62. Manage Health Care Challenges Constant change Demanding Continuous improvement & flexibility

63. Manage Health Care Challenges Doing morewith less

64. Disrupt status quo… Thinking differently… Seeing differently…

65. Reinvent your organization, your strategy, your marketing, your image

66. Reinvent your organization, your strategy, your marketing, your image

67. Continuous Improvement Innovation

68. These are extraordinary times which require extraordinarysolutions

69. Manage “Patient-Centered” Solutions Pebble Project Plane Tree Lean Six Sigma Digital Simulations EDAC

70. Manage Collaboration Trends “Design thinking” is more than one discipline... It requires interdisciplinary innovation

71. Manage Program at a Glance

72. Manage Site Plan

76. Manage The Care Team Core

78. Manage The Galleria Lobby Patient-Centered Environments

79. Manage The Galleria Lobby

80. Manage The Galleria Lobby

81. Manage The EHR Enabled Exam

82. Manage The Digitally Enabled OR

83. Manage Shared Physician Lounge

84. Manage The Care Team Core

86. And just in case you think this project consumed the entirety of the past two years…

88. QUESTIONS? Dr. Randall Huss: Randall.Huss@Mercy.Net Gerald Dowdy: Gerald.Dowdy@Mercy.Net Miguel Burbano de Lara: miguel.burbano@neenan.com