Productivity Recommendations

295 295 Case 3 291 372 Physician Care Services, Inc. 875 291 Copyright © 2013. Health Administration Press. All rights reserved. P hysician Care Services, Inc. (PCS), was founded as a for-profit corporation on January 1, 2000. Three physicians each own 20 percent of the stock, and one physician owns 40 percent. PCS currently offers nonemergent care services in two locations—at the Alpha Center just outside the city limits of Middleboro in Mifflenville and at the Beta Center in Jasper, close to the Jasper industrial park and suburban neighborhoods. At these locations ambulatory medical care is provided on a walk-in basis. PCS centers do not offer emergency services. If a patient arrives needing emergency services, an ambulance is called to transport the patient to the nearest hospital emergency department. The Alpha Center opened in January 2000. Originally, it only treated occupational health clients. This policy was changed in 2004 when private patients were accepted. The Beta Center opened in January 2006 and has always treated private as well as occupational health clients. PCS specializes in providing services that are deemed convenient by the general public. Patient satisfaction remains its highest operational goal. At present, staff physicians employed by PCS do not provide continuing medical care. PCS physicians refer patients to area physicians as warranted for continuing and/or specialized medical care. Although patients often return to a PCS center, chronic illness management is not provided. 77 Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Copying healthcare strategy and operations. from and distribution of Retrieved this PDF is http://ebookcentral.proquest.com prohibited without written permission. Created from waldenu on 2018-06-30 06:15:13. For permission, please contact Copyright Clearance Center at www.copyright.com 00_SeidelLewis (2258).indb 77 11/22/13 8:44 AM 78 The Middleboro Casebook P ati e n t S e r v ic e s O ccu pat i o n a l H e a lt h C l i e n t s Occupational health clients are sent to a PCS center by their employer for treatment of a work-related injury (which is usually covered by workers’ compensation insurance), for pre-employment or annual physicals, and for health testing, which are paid for directly by the employer. Because of special work conditions, usually involving hazardous chemicals or materials, some local corporations contract with PCS to provide comprehensive physicals in accordance with Department of Transportation and other federal and state laws and regulations. Local corporations consider PCS a cost-effective and convenient alternative to a hospital emergency department. These corporations use PCS in lieu of employing a physician. Corporate clients expect PCS to assist with all phases of case management involving worker injury. They hold PCS accountable that their workers receive timely, appropriate, and cost-effective services. Physicals for Occupational Safety and Health Administration compliance are currently priced between $300 and $500 each. Physicals for local police and fire include pulmonary function tests (PFT), laboratory tests, and electrocardiograms (EKGs). They are currently priced between $250 and $350 per physical, depending on contractual volume. Pre-employment physicals are typically priced between $60 and $95 and include a urine dip test. Services provided for occupational health clients are billed directly to the employer. P r i vat e (R e ta i l ) C l i e n t s Copyright © 2013. Health Administration Press. All rights reserved. Private clients also seek medical care from PCS centers. All aspects of general medical care are provided except OB/GYN. Private patients are attracted to PCS because they do not need an appointment. PCS accepts cash, checks, and credit cards at time of service. As of 2008, PCS directly bills the larger health insurance plans covering its market area: ◆◆ Statewide Blue Shield ◆◆ American Health Plan ◆◆ Cumberland River Health Plan ◆◆ Central State Good Health Plan At time of service, retail clients covered by these plans are screened to verify eligibility and to determine whether they have satisfied any required deductibles. If deductibles have been met, patients will be required to pay just the copay amount, and a bill is sent electronically to the insurance plan for the account’s balance. If deductibles have not been Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Copying healthcare strategy and operations. from and distribution of Retrieved this PDF is http://ebookcentral.proquest.com prohibited without written permission. Created from waldenu on 2018-06-30 06:15:13. For permission, please contact Copyright Clearance Center at www.copyright.com 00_SeidelLewis (2258).indb 78 11/22/13 8:44 AM Case 3: Physician Care Services, Inc. 79 met, then the patient will pay the bill at time of service, and PCS will enter the bill into the insurance company’s system as partial fulfillment of any outstanding deductible. If the patient does not have coverage from one of these insurance companies, she receives a bill to claim reimbursement directly from her insurance plan. PCS also directly bills Medicare. A recent study suggested that these four private insurance companies and Medicare cover approximately 85 percent of PCS’s private clients. Any client who has a history of bad debt at PCS or is unable to pay at time of service is referred to a hospital emergency department for service. PCS maintains an aggressive credit and bad debt collection policy and does not serve Medicaid patients. Patients living within a 30-minute travel distance from a PCS center typically constitute 80 percent of PCS’s private pay patients. Copyright © 2013. Health Administration Press. All rights reserved. O r g a ni z ati o n and M a n a gem ent Each center is located in approximately 6,000 square feet of rental space devoted to patient services. The Alpha Center is located on main roads between Middleboro and Mifflenville in a small shopping center. The Beta Center is located on the first floor of a new office building adjacent to a large shopping mall in Jasper. Ample parking is provided in both locations. Each center maintains attractive signs. Each center is open 60 hours per week, 8:00 a.m. to 7:00 p.m. on weekdays and 9:00 a.m. to 2:00 p.m. on Saturdays. Both centers are closed on Sundays and Memorial Day, July 4, Thanksgiving, Christmas, and New Year’s Day. Each center has four fully furnished patient examination rooms and one extra room. Currently each center has some excess space. For patient care the minimum staffing at each center is one receptionist/billing clerk, one medical assistant, and one physician or nurse practitioner. Additional staff (e.g., advanced registered nurse practitioner, physician assistant, medical assistant) is scheduled based on anticipated high-volume days. Typically the nurse practitioner works on Saturdays and assists with physicals and other services on high-volume days. Physician assistants also assist on high-volume days. The central administrative and billing office is an additional 2,500 square feet and is located adjacent to Alpha Center. The central office staff includes the president, medical director, director of nursing and patient care, business office manager, and the billing and bookkeeping staff. Charges Each center uses the same price schedule. The basic visit charge (CPT 99202) has changed each year. Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Copying healthcare strategy and operations. from and distribution of Retrieved this PDF is http://ebookcentral.proquest.com prohibited without written permission. Created from waldenu on 2018-06-30 06:15:13. For permission, please contact Copyright Clearance Center at www.copyright.com 00_SeidelLewis (2258).indb 79 11/22/13 8:44 AM 80 The Middleboro Casebook January–December Private Pay ($) Occupational ($) 2010 94 161 2011 99 170 2012 104 180 2013 110 189 2014 120 201 Current detailed prices include: CPT Procedure Copyright © 2013. Health Administration Press. All rights reserved. Code Description Price ($) 99201 Office visit, brief, new 96 99202 Office visit, limited, new 120 99203 Office visit, inter, new 201 99204 Office visit, comp, new 226 99211 Office visit, min, est 65 99212 Office visit, brief, est 96 99213 Office visit, limited, est 201 99214 Office visit, inter, est 201 99215 Office visit, comp, est 294 Additional charges are levied for ancillary testing and specialized physician services, such as suturing. A patient returning for a medically ordered follow-up is charged $96 for the return visit. Based on Current Procedural Terminology (CPT) comparison, PCS fee levels are competitive within the area. No similar medical service is offered within a 45-minute radius from each center. In the past—as part of an advertising campaign to attract private pay patients—each May and June PCS has offered discounted physicals, such as camp physicals for children at $48 and for all children in a family for $69. Steve J. Tobias, MD, board chair and president of PCS, says national studies suggest that urgent care visits are at least $10 less than a visit to primary care physician in Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Copying healthcare strategy and operations. from and distribution of Retrieved this PDF is http://ebookcentral.proquest.com prohibited without written permission. Created from waldenu on 2018-06-30 06:15:13. For permission, please contact Copyright Clearance Center at www.copyright.com 00_SeidelLewis (2258).indb 80 11/22/13 8:44 AM Case 3: Physician Care Services, Inc. 81 private practice. Other studies indicate that urgent care visits cost $250 to $600 less than emergency department visits for the same CPT code. Some occupational health clients are charged based on a negotiated volume-based price, especially for physicals. PCS’s medical director negotiates specific fees for physicals and specific medical tests ordered by an employer. Typically, an employer approaches PCS in need of a specific type of physical, such as the annual physical required by the Department of Transportation for all operators of school buses, or specific medical test for employees. PCS submits a bid to perform a specific number of physicals based on a flat rate per physical. As of 2007, PCS does its own payroll. Employees must have direct deposit with a local bank. Each employee receives an electronic pay stub biweekly (with accrued balance of vacation and sick time) and a W-2 at the end of the year. Board of Directors Copyright © 2013. Health Administration Press. All rights reserved. The board of directors is composed of the four physician owners and meets quarterly to review operations. The annual board meeting occurs in December, at which time officers are elected for the coming year. As majority stockholder, Dr. Tobias is chairman of the board and president of PCS. Jay T. Smooth, MD, is the board secretary. Other board members are Rita Hottle, MD, and Laura Cytesmath, MD. Current owners have the option of buying any available stock at its current book value. An outsider can purchase stock in this company only if all the current owners refuse to exercise this option and he receives the approval of the existing owners. It should be noted that PCS has paid a stock dividend in three of the last five years. President and M e d ic a l D i r e c t o r Dr. Tobias is also the medical director of PCS. He is a graduate of the medical school at Private University and has completed postgraduate medical education at Walter Reed Army Hospital in general internal medicine. He is board certified in general internal medicine, emergency medicine, and occupational health. He also holds a master’s in public health from State University. As medical director, Dr. Tobias is responsible for medical quality assurance programs and the recruitment and retention of qualified physician employees. He is also responsible for securing the services of consulting radiologists to read all X-rays. He receives a separate salary as medical director and as president. Compensation for the medical director position began in 2008. Before Dr. Tobias founded PCS, he was a full-time emergency physician at Middleboro Community Hospital. He originally worked to establish joint venture urgent care centers with Middleboro Community Hospital. When this approach failed, he recruited the other stockholders and moved ahead with PCS. As president, Dr. Tobias is responsible for the management of all resources and strategic planning. Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Copying healthcare strategy and operations. from and distribution of Retrieved this PDF is http://ebookcentral.proquest.com prohibited without written permission. Created from waldenu on 2018-06-30 06:15:13. For permission, please contact Copyright Clearance Center at www.copyright.com 00_SeidelLewis (2258).indb 81 11/22/13 8:44 AM 82 The Middleboro Casebook Dr. Tobias schedules the other physicians and the nurse practitioners. He also works in the centers and provides on-call services as needed. He has consulting medical staff privileges in the Department of Medicine at Middleboro Community Hospital. C l i n ic a l S ta f f In total, the clinical staff is composed of seven physicians, three nurse practitioners, and two physician assistants. All physicians hold medical staff privileges at an area hospital. Name Medical Specialty Certification Bennet Casey, MD Family practice Board certified Mark Welby, MD Family practice Board certified Steve Tobias, MD, MPH ** Emergency medicine Board certified Jay Smooth, MD * Emergency medicine Board certified Rita Hottle, MD * Emergency medicine Board certified Laura Cytesmath, MD * Emergency medicine Board certified Micah Foxx, DO, MPH Occupational health Board certified Melisa Majors, MD Occupational health Board certified Carl Withers, ARNP Family and adult health Jane Jones, ARNP Family and adult health Gerri Mattox, ARNP Family and adult health Copyright © 2013. Health Administration Press. All rights reserved. Rutherford Hayes, PA Mary Fishborne, PA * Owner ** Owner and president Until 2007, staff physicians were retained as independent contractors and received no benefits above their hourly wage. Beginning in 2007 when nurse practitioners were added, physicians (and all other employees) who worked more than 1,000 hours were provided comprehensive benefits, including family medical coverage. Also as of 2007, PCS reimburses all physicians and nurse practitioners for their medical malpractice insurance. Full coverage is provided when a member of the medical staff works 1,400 hours at PCS. Others receive a partial reimbursement. Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Copying healthcare strategy and operations. from and distribution of Retrieved this PDF is http://ebookcentral.proquest.com prohibited without written permission. Created from waldenu on 2018-06-30 06:15:13. For permission, please contact Copyright Clearance Center at www.copyright.com 00_SeidelLewis (2258).indb 82 11/22/13 8:44 AM Case 3: Physician Care Services, Inc. 83 Physicians are paid $100 per hour. Nurse practitioners receive $50 per hour. These payment levels have been fixed for two years and are considered within the appropriate market range. Drs. Smooth, Hottle, and Cytesmath also work as emergency physicians at Middleboro Community Hospital. Dr. Casey serves as medical director one day per week at an area corporation, where he specializes in occupational health. Dr. Welby also works at Convenient Med Care, Inc., in Capital City. Dr. Foxx, who recently relocated to Jasper with her family, is available to work no more than six shifts per month, a condition she has established until her children reach school age. Dr. Majors also works as an emergency physician in Capital City. Physician assistants are paid $40 per hour and assist physicians on anticipated high-volume days. Dr. Tobias schedules all members of the medical staff for work on a monthly basis with the understanding that if a physician is unable to work, it is her responsibility to secure a replacement from the qualified medical staff of PCS. Physicians and nurse practitioners work an entire shift (e.g., 11 hours on a weekday). Fridays and Saturdays are typically assigned to the nurse practitioners. Physician assistants are on call for busy days to assist physicians. The clinical staff of PCS meets quarterly to review areas of concern. Dr. Tobias does random reviews of medical records to ensure compliance with standards of clinical practice. He is also responsible for all issues involving credentialing. M e d ic a l A s s i s ta n t s Copyright © 2013. Health Administration Press. All rights reserved. Medical assistants at each center are trained to take limited X-rays, draw specimens for laboratory testing, do EKGs, and conduct simple vision and audiometric examinations. Each center is equipped to do: 1. On-site X-ray 2. PFT 3. EKG 4. Audiometric and visual testing 5. Some laboratory testing (e.g., strep screen, dip urine) 6. Drug and breath alcohol testing A regional laboratory processes more advanced laboratory work. Two medical assistants are assigned to each weekday shift. One is assigned for 7 hours per day (i.e., 35 hours per week) and the other is assigned for 4 hours per weekday and Saturdays (i.e., 25 hours per week). Responsibilities include examination room Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Copying healthcare strategy and operations. from and distribution of Retrieved this PDF is http://ebookcentral.proquest.com prohibited without written permission. Created from waldenu on 2018-06-30 06:15:13. For permission, please contact Copyright Clearance Center at www.copyright.com 00_SeidelLewis (2258).indb 83 11/22/13 8:44 AM 84 The Middleboro Casebook preparation, assisting the physician or nurse practitioner, patient testing, case management, scheduling visit follow-up care, and addressing patient questions. Each center maintains a pool of qualified medical assistants who are trained, evaluated, and scheduled by the director of nursing and clinical care. C e n t r a l O f f ic e S ta f f Dr. Tobias devotes his time to being both the president and medical director at PCS and filling in at a center when needed. As president he is responsible for the overall management of PCS. Joan Carlton, LPN, is director of nursing and clinical care. She trains, supervises, and schedules the medical assistants. She is also responsible for ordering medical supplies, meeting with occupational health employers as needed, and general administrative duties as assigned by Dr. Tobias. If needed, she substitutes for a medical assistant at a center. Martha Coin directs the business office and has three full-time staff. She schedules the receptionist staff at each center. She and her staff assist the receptionists and billing clerks at each center, manage all insurance billing, and manage the general ledger, including accounts payable and accounts receivable. If needed, she or a member of her staff substitutes for the receptionist at a center. The central office billing staff also maintains a list of available (and trained) fill-in receptionists to cover absences and other needs. R e c e p t i o n i s t S ta f f Copyright © 2013. Health Administration Press. All rights reserved. One full-time (35 hours per week) front desk receptionist is hired for each center. Aside from greeting and registering all patients, the receptionist is also responsible for appointments, billing, records for occupational clients, and managing cash receipts. One or more additional receptionists are hired for the remaining 25 hours per week. A d d i t i o n a l I n f or m ati on In 2008 PCS began using URGENT CARE MIS, an electronic medical information, general ledger, and billing system. Computer terminals were installed in the reception area in each center, at the central office, and in each examination room. PCS uses this system for all phases of financial and medical record keeping and billing, appointment services, case management, staff scheduling, and data management. This system captures, stores, and reports all CPT codes and links medical procedures with revenue and expense information. The health insurance billing system has a direct Internet link with the participating insurance companies and Medicare. PCS purchased the hardware and leased the required Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Copying healthcare strategy and operations. from and distribution of Retrieved this PDF is http://ebookcentral.proquest.com prohibited without written permission. Created from waldenu on 2018-06-30 06:15:13. For permission, please contact Copyright Clearance Center at www.copyright.com 00_SeidelLewis (2258).indb 84 11/22/13 8:44 AM Case 3: Physician Care Services, Inc. 85 software for ten years. It receives hardware maintenance, software updates, and technical assistance from the vendor. A 2013 study of medical records indicated that the most common CPT codes at PCS are ◆◆ 99212/3 and 99202 Office/Outpatient Visit, ◆◆ G0001 Drawing Blood, ◆◆ 85029 Automated Hemogram, and Copyright © 2013. Health Administration Press. All rights reserved. ◆◆ 71010/2 Chest X-Ray. Injuries and rechecks generally account for 20 percent of all visits. Paper medical records that existed prior to 2008 are retained in active file for seven years, and then transferred to closed files. When interviewed, Dr. Tobias indicated that discharging Nancy Stone, RN, as director of nursing and clinical services in 2012 was a hard decision. Some employees still regret this situation. Stone was well liked but just could not get along with some of the physicians and had a great deal of difficulty coping with multiple job responsibilities. At the end of her tenure she refused to provide patient care as needed at the Beta Center. After she was discharged, Stone complained that she had “too many duties to do well, and PCS was more interested in getting patients in and out than in providing patients quality medical care.” She has retained an attorney and informed Dr. Tobias that she is suing him and PCS for “wrongful discharge.” As she stated at the initial hearing for the lawsuit, “Meeting job expectations was hard when the job lacked any formal job description.” Dr. Tobias shared in the interview that he felt compelled to act even though Stone is the sister of the vice president for human resources at Carlstead Rayon, a growing occupational health client of the Alpha Center, and that additional details are not available given that this case is currently being handled by legal counsel. Dr. Tobias stated that the owners should look forward to achieving even greater corporate profitability. Dr. Tobias indicated that no one foresaw the terrible first three years of financial losses. He also said that within the past few years, PCS has earned its place in the regional medical care system and its future appears solid. It should be noted that, at the end of 2007, one of the original physician partners, who is no longer affiliated with PCS, exercised his option to be bought out by another stockholder. Dr. Tobias was the only partner willing at that time to increase his ownership in PCS. Dr. Tobias also indicated that the owners might now be in the position to open a third and even fourth location. He also discussed purchasing buildings to house the existing centers and adding some services to better serve their occupational and private pay clients. Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Copying healthcare strategy and operations. from and distribution of Retrieved this PDF is http://ebookcentral.proquest.com prohibited without written permission. Created from waldenu on 2018-06-30 06:15:13. For permission, please contact Copyright Clearance Center at www.copyright.com 00_SeidelLewis (2258).indb 85 11/22/13 8:44 AM 86 The Middleboro Casebook Copyright © 2013. Health Administration Press. All rights reserved. “We are a debt-free corporation that is beginning to earn serious profits,” he said. “Along the way we have distinguished ourselves by the high quality of care we have provided—our patients and occupational health clients are delighted with our highestlevel commitment to patient care, convenience, and affordable prices. While it has been a long road, I have every reason to believe we will continue to prosper and expand.” The original real estate leases on the Alpha and Beta Centers expire at the end of 2015. Dr. Tobias said that he timed the expiration of these leases to coincide with when PCS would be ready to make a major strategic move. Each current lease has a renewal clause for up to 36 months, with an escalation clause so that rents do not increase more than 15 percent per year. Tobias estimates that appropriate facilities could be acquired for $150 per square foot (including land, site improvements, and facilities) and that it would take approximately six months from the time the contract was executed to when the center could be fully operational. When asked to identify future challenges, Tobias noted that he felt that volume had just about hit the level at which total service time averages about 20 minutes. He did indicate, however, that there might be a need for larger waiting rooms and that those patients waiting for more than 90 minutes might be a problem. Tobias was, however, pleased that patients generally reported “complete satisfaction” with the quality of care provided by PCS. Dr. Tobias repeatedly cited the competent clinical and administrative staff. Overall, he indicated that he was concerned about continued rapid growth. “Our early success with occupational health may be slowing. If we lose a significant amount of manufacturing in our area, we potentially lose occupational health clients. Our future in occupational health will follow the local economy.” Dr. Tobias noted that regional unemployment has already affected occupation health. Fewer people are being hired and working. Fees paid by the workers’ compensation program have been fixed for 24 months. People who are unemployed lack health insurance. Dr. Tobias expressed a great deal of optimism that the full implementation of the new federal health insurance plan (the Patient Protection and Affordable Care Act) would significantly expand PCS’s pool of private clients. Two years ago, PCS instituted an appointment plan for occupational health clients, which Dr. Tobias reported has been very successful. Under this plan, occupational health clients are scheduled for physicals or medical testing. Under the “call before you come” system, patients (or employers) can call ahead to determine the approximate wait time, make a decision, and—if they want service—register for service at an approximate time that day, thereby ensuring themselves a specific place in the queue for service even before they arrive at a center. Every patient who arrives at a center is given an approximate wait time by the receptionist and told they need not wait in the waiting area to preserve the scheduled time for their appointment. While “first in, first out” is generally used, urgent care cases (especially injuries) are bumped ahead of nonemergency patients. Signs in the waiting area Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Copying healthcare strategy and operations. from and distribution of Retrieved this PDF is http://ebookcentral.proquest.com prohibited without written permission. Created from waldenu on 2018-06-30 06:15:13. For permission, please contact Copyright Clearance Center at www.copyright.com 00_SeidelLewis (2258).indb 86 11/22/13 8:44 AM Copyright © 2013. Health Administration Press. All rights reserved. Case 3: Physician Care Services, Inc. 87 explain to patients that some occupational health clients are served by appointment and that appointments override arrival order. PCS advertises its services in the regional market. It uses billboards on main roads and newspaper advertising. It also uses an extensive website and social media. The director of nursing and patient care visits current and prospective occupational health clients and typically answers approximately 15 to 25 telephone inquiries per month regarding quotes for specific services, such as employee physicals. When interviewed, other PCS physicians offered different perspectives. Three physicians expressed concern about the manner in which Dr. Tobias schedules the physicians. They were never sure exactly how many shifts per month they would work and at which center. All prefer to work at only one center and indicated that this type of stability leads to a better medical care team. Records suggest that certain physicians may have productivity profiles significantly different from those of other physicians. It appears that on busy days, revenue per visit drops, a trend that suggests that physicians do less ancillary testing when they are busy. The target for physicians and nurse practitioners is 3 to 4 patients per hour. Three physicians have also requested extra compensation for busy days. They contend that they tend to be scheduled on “very busy days” and receive the same hourly compensation as physicians who work on slower days. Dr. Tobias indicated that he does not feel that their claim is warranted. In 2010, two (nonowner) physicians said that because they are paid by the hour, they should be paid for the time they spend treating those patients who arrive right before closing time. Up until this change, all staff were only paid for the hours in their shift (e.g., 11 hours), which was sometimes less than the number of actual hours worked. Employees are expected to treat all patients that arrive during working hours even if this extends their work time beyond closing time. All physicians reported that they felt that their pay level was reasonable given their responsibilities. Six occupational health nurses at area corporations were interviewed. Each indicated that she and her corporation were satisfied with PCS. A number of these nurses indicated that they appreciated PCS—specifically the medical assistants—keeping them informed about specific patients and that PCS was creative in explaining restriction and suggesting “light duty,” medically appropriate work an injured worker could perform for the employer as an alternative to her regular duties until she was ready to resume her regular duties. Dr. Tobias recently returned from a professional meeting with statistics that he felt could help PCS better estimate its future market. These statistics apply to this state: Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Copying healthcare strategy and operations. from and distribution of Retrieved this PDF is http://ebookcentral.proquest.com prohibited without written permission. Created from waldenu on 2018-06-30 06:15:13. For permission, please contact Copyright Clearance Center at www.copyright.com 00_SeidelLewis (2258).indb 87 11/22/13 8:44 AM 88 The Middleboro Casebook Average Number of Physician Visits—Ambulatory Care per Person, per Year, by Age and Sex (National Statistics) Age Males Females 0–14 3.37 3.09 15–44 1.99 3.92 (includes OB/GYN) 45–64 2.98 4.34 65+ 4.51 5.19 NOTE: Visits unrelated to workers’ compensation and occupational health At this meeting, Dr. Tobias also learned that other urgent care corporations use the following parameters in their fiscal and market planning. ◆◆ For every 15 percent increase in a basic visit fee, there will be a 25 percent reduction in utilization of retail patients without health insurance (i.e., who pay by cash, check, or credit card). ◆◆ Patients covered by insurance, including Medicare and commercial insurance, are generally not price-sensitive as long as the annual increase in the basic visit fee does not exceed 20 percent. Copyright © 2013. Health Administration Press. All rights reserved. ◆◆ Annual increases up to 15 percent in ancillary charges do not affect the number of new visits by retail clients. It appears that ancillary charge increases above 15 percent may reduce return visits by as much as 45 percent regardless of payment source. At the next board meeting, Dr. Tobias plans to discuss a series of new ideas and opportunities that deserve the board’s attention. Currently his ideas and opportunities include the following: Prescription Drugs for R e ta i l P at i e n t s This service is currently available to patients covered by workers’ compensation. State law allows physicians (and nurse practitioners) to dispense prescription drugs as long as adequate records are maintained. National firms specializing in drug repackaging let PCS buy prepackaged prescription drugs ready for sale to a patient. PCS has already established its formulary Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Copying healthcare strategy and operations. from and distribution of Retrieved this PDF is http://ebookcentral.proquest.com prohibited without written permission. Created from waldenu on 2018-06-30 06:15:13. For permission, please contact Copyright Clearance Center at www.copyright.com 00_SeidelLewis (2258).indb 88 11/22/13 8:44 AM Case 3: Physician Care Services, Inc. 89 Copyright © 2013. Health Administration Press. All rights reserved. for workers’ compensation patents. PCS has determined that by maintaining 12 specific drugs in pill form it can meet approximately 60 percent of the retail demand that PCS physicians create for prescription drugs. The charge for prescription drugs for workers’ compensation patients is directly billed to the employer as part of the overall charge for service. Dr. Tobias indicated that PCS should consider extending this service to all patients. By only providing “high-volume” drugs, PCS can guarantee high inventory turnover. An appropriately sized initial inventory for retail patients can be capitalized for a center for $1,000. All suppliers promise a next-day replenishment of inventory items. The shelf life of all drugs is more than one year. Even with a markup of 800 percent, PCS prescription prices will be competitively priced in the area. The question is whether this service should be expanded to retail patients. By reviewing medical records of current retail patients (nonphysicals), PCS has determined the number of prescriptions received per visit by patients. Age of Patients Average Number of Prescriptions Received per Visit 0–14 1.20 15–44 0.80 45–64 1.10 65+ 1.90 The average supplier cost per PCS prescription is estimated to be $5. To maintain the proposed inventory, additional software costing $12,500 per year is required to verify insurance coverage and copays and process insurance payments. Dr. Tobias would like to potentially begin this service within six months. Questions remain, however, whether any prescriptions issued by PCS should be refilled without another medical visit. Questions also remain as to billing procedures when patients do not have a current prescription plan card at time of service. An urgent care center in Capital City recently ended its pharmaceutical sales to retail patients because of the high number of refused claims by drug plans. Drug Testing for H e a lt h y E m p l o y e e s The director of human resources at a local company, a current PCS occupational health client, has stated that its new labor contract includes a clause stating that “all workers and job applicants are subject to mandatory random drug testing and any worker who fails or refuses the test will be immediately discharged or not hired.” The client has asked PCS to perform drug tests on referred workers or job applicants. Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Copying healthcare strategy and operations. from and distribution of Retrieved this PDF is http://ebookcentral.proquest.com prohibited without written permission. Created from waldenu on 2018-06-30 06:15:13. For permission, please contact Copyright Clearance Center at www.copyright.com 00_SeidelLewis (2258).indb 89 11/22/13 8:44 AM 90 The Middleboro Casebook Note that under the new state law and workers’ compensation regulations, drug testing is also required for all workers who are injured at work. Employers are also able to institute random drug testing. Some other clients have even requested that PCS select some of their workers for testing using a random selection process. A process using employee Social Security numbers has been discussed. Other occupational health clients have previously suggested that PCS begin this type of service. Currently a test is available from a reference laboratory for a processing cost of $8 per test. Results screen for the presence of all common illegal drugs. The list price for this test is $42 and $63 if a certified medical review officer (MRO) reads the test. Dr. Tobias is a certified MRO. The test requires about 10 minutes of a medical assistant’s time, specifically to maintain compliance with the chain of custody protocol during collection. P h y s ic a l s by Appointment for Employees Increasingly, employers are issuing formal requests for proposal (RFPs) for occupational health physicals that require appointments. For example, a current RFP from a local employer is for 350 annual physicals during 2015 that must be done between 3:15 p.m. and 4:30 p.m. Monday through Friday at the Beta Center. (The company’s employees work 7:00 a.m. to 3:00 p.m.) The physical must include the following components: Copyright © 2013. Health Administration Press. All rights reserved. PCS List Price Medical history and examination $70 EKG $70 X-ray chest $101 Urine (dip) test $20 Complete blood count with differential $40 Vision screen $27 Audiometric test $3 Each physical will take approximately 80 minutes to complete. The PCS list price for this package of services and tests is $331. PCS vendor costs for the physical (e.g., X-ray reading fees, laboratory charges) are estimated to be $70.00. The PCS bid for this contract will be evaluated on the basis of total price and fulfilling expectations related to schedule and timing. Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Copying healthcare strategy and operations. from and distribution of Retrieved this PDF is http://ebookcentral.proquest.com prohibited without written permission. Created from waldenu on 2018-06-30 06:15:13. For permission, please contact Copyright Clearance Center at www.copyright.com 00_SeidelLewis (2258).indb 90 11/22/13 8:44 AM Case 3: Physician Care Services, Inc. 91 Currently, this employer uses the emergency department at Middleboro Community Hospital for all matters involving occupational health. Dr. Tobias feels that the board must develop policies regarding these types of requests. M a n a g e m e n t P o l ici e s C o n c e r n i n g W a i t i n g Copyright © 2013. Health Administration Press. All rights reserved. Dr. Tobias is concerned that patient waiting time may be a problem. Waiting appears to be defined by patients as the time they spend in a reception area, not the time they might spend in an examination room waiting to see the clinical staff. National studies indicate that approximately 57 percent of patients coming to an urgent care center wait 15 or fewer minutes. Dr. Tobias will tell the board that PCS must begin to address this problem after they first have a better understanding of current waiting times and issues. A consultant has told PCS that its service times for retail patients are approximately 20 percent of gross billed charges. For example, a patient visit that costs $100 (gross billed charges) takes approximately 20 minutes—20 percent of 100—of service time. For all workers’ compensation cases and employer-paid physicals, service time is approximately 25 percent of gross billed charges. As demand increases during the day, the clinical care team sequentially sees patients in multiple examination rooms. Typically, a visit begins with a brief encounter with the medical assistant, who records vital signs, takes a medical history, and records the reason for the visit. The physician or nurse practitioner then enters the room (with the chart) and performs an additional examination. Specific medical tests may be ordered. The medical assistant administers these tests (e.g., X-ray) and/or collects blood or urine for laboratory processing. The physician or nurse practitioner ends the visit providing the patient with a specific diagnosis and treatment plan, additional medical orders, or a referral. A mbu l at o ry P h y s ic a l T h e r a p y National studies estimate that approximately 30 percent of the occupational health clients (injuries covered by workers’ compensation) and 5 percent of retail clients (nonphysicals) at centers like PCS are referred to physical therapy for treatment. Dr. Tobias has indicated that PCS may have the opportunity to move into this market. Area providers typically receive $195 from workers’ compensation funds for an initial physical therapy evaluation and (on average) $125 per therapy visit. On average each workers’ compensation case generates 5.75 visits—an initial visit and 4.75 additional visits. Most commercial and managed care plans pay $60 per visit and $100 for an initial evaluation. Dr. Tobias has recommended that PCS consider, depending on estimated demand, offering physical therapy services for one or both centers (e.g., 7:00 a.m. to 2:00 p.m. Monday, Wednesday, and Friday and 11:00 a.m. to 7:00 p.m. on Tuesday and Thursday). Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Copying healthcare strategy and operations. from and distribution of Retrieved this PDF is http://ebookcentral.proquest.com prohibited without written permission. Created from waldenu on 2018-06-30 06:15:13. For permission, please contact Copyright Clearance Center at www.copyright.com 00_SeidelLewis (2258).indb 91 11/22/13 8:44 AM 92 The Middleboro Casebook Staffing could include one full-time physical therapist (PT) at $80 per hour (or $75,000 plus benefits) and part-time physical therapy assistants (PTAs) at approximately $25 per hour. PTs can simultaneously manage between two and five patients and supervise a PTA, who provides the direct therapy, given specific treatment plans. Dr. Tobias also says that PCS may be able to contract for the needed PT and PTAs from local nursing homes. The PT must do the initial patient evaluation and establish the treatment plan but need not be on site to supervise the PTAs. Equipment for each center could be purchased and installed for approximately $30,000 (five year depreciation, no salvage value). Operational costs, such as laundry and medical supplies, are estimated to add approximately $15 per visit. The one-time information system upgrade for ambulatory physical therapy would cost $6,500. Other costs may need to be estimated. A consultant has recommended that PCS only service workers’ compensation patients to start, but Dr. Tobias indicates that full coverage needs to be considered. O t h e r I s s ue s Copyright © 2013. Health Administration Press. All rights reserved. The board members know that one member of the board will come to the next board meeting in hopes of discussing whether PCS is for sale and how best to position PCS for sale. He believes that PCS cannot be a long-term successful player in the increasingly competitive medical marketplace. He stated, “I am very concerned that the big box stores will add walk-in services to go along with their pharmacies. I just do not see how we can compete. Our market area is just too volatile!” It is known that Dr. Tobias has always said he would be willing to sell PCS for “the right price.” He has also stated when the regional economy and manufacturing pick up, PCS’s occupational health business should rebound along with its overall profits. PCS is liable for a 31 percent federal tax and 9 percent state tax on its profits. Carry-forward losses experienced in the initial years of operation have expired. Local real estate taxes on owned land and buildings are 4 percent of assessed valuation. Current assessed valuation of land in the county is approximately 40 percent of market value or total development cost. Originally three-year renewable leases were used to secure the needed medical equipment (e.g., X-ray machines, computers) and most furniture. In 2005 PCS’s accountant recommended that because PCS was now earning a profit and had used all of its carry-forward tax credits, it should consider borrowing funds to purchase needed equipment and should cancel all outstanding equipment leases. Between 2005 and 2007, it did. Each center required between $150,000 and $200,000 worth of new equipment. The only equipment leases that remain are for color copiers and general office equipment. PCS maintains a line of credit with a commercial bank in Capital City. Its cost of capital is 2.5 percent above the Wall Street Journal prime rate. Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Copying healthcare strategy and operations. from and distribution of Retrieved this PDF is http://ebookcentral.proquest.com prohibited without written permission. Created from waldenu on 2018-06-30 06:15:13. For permission, please contact Copyright Clearance Center at www.copyright.com 00_SeidelLewis (2258).indb 92 11/22/13 8:44 AM Case 3: Physician Care Services, Inc. 93 Copyright © 2013. Health Administration Press. All rights reserved. Based on its annual credit review, PCS has been informed that its cost of capital could increase by 1 or 1.5 percentage points over the next 18 months. The bank stated that the management and organization of PCS are seriously flawed: “PCS has become too dependent on Dr. Tobias in his many roles. His duties need to be divided between two or more qualified professionals.” If PCS does not address this situation, its credit worthiness will be significantly downgraded. This situation was also noted in the 2013 audit and management letter. Officials in the City of Jasper have requested a meeting with PCS to discuss emergency planning and expanded services. Their specific questions will include whether PCS would expand hours on Saturday and offer services on Sunday afternoon. Their letter indicated that the majority of urgent care centers nationally offer services on Saturdays (8:00 a.m. to 8:00 p.m.) and Sundays (9:00 a.m. to 7:00 p.m.). A formal response to this inquiry is due within the week. Additional information regarding PCS utilization, patient demographics, and finances may be found in the following tables. Seidel, L. F., & Lewis, J. B. (2013). Middleboro casebook : Copying healthcare strategy and operations. from and distribution of Retrieved this PDF is http://ebookcentral.proquest.com prohibited without written permission. Created from waldenu on 2018-06-30 06:15:13. For permission, please contact Copyright Clearance Center at www.copyright.com 00_SeidelLewis (2258).indb 93 11/22/13 8:44 AM Week 5 Assignment: Productivity Metrics Emi Beery WALDEN UNIVERSITY Physician Care Services, Inc. is facing a number of challenges that may end up hindering its productivity in the provision of private and occupational services to patients. Nonetheless, there are equal opportunities that the healthcare facility can exploit to ensure that it overcomes the challenges and provide services to the expectation of is clients. To achieve this objective, the facility must evaluate its performance based on certain productivity metrics to achieve a high level of productivity. Below are some of the productivity metrics that can be used to evaluate the productivity of the organization health services The Metric(S) That Can Be Used To Evaluate the Productivity of Physician Care Services, Inc. Physician Care Services, Inc. productivity may be categorized into operations, finance, emergency, and care. For the private and occupational health patients, the patients wait time and an average number of patients’ rooms in use at any given time will be good performance metrics to measure the effectiveness of providing services (Joint Commission Resources, Inc.., 2013). The efficiency of the current staff to appetent ratio in these two sections as well as the bed turnover rate will also help in ascertaining the level of efficiency in the admission of patients. The frequency of communication between the various medical staff in the facility will also provide good performance metric data to evaluate the productivity of the health facility. Since the facility bills, most of its private patients through insurance firms, the productivity based on financial management and reimbursement will be ascertained based on the rate at which its insurance claims are denied (Lighter & Lighter, 2013). Equally, the average charge on every treatment offered as well as the average cost and time taken to process the insurance claim would provide an accurate productivity metric for the facility. The wages of the hospital staff and their relative output to the facility will also be used to measure the productivity of the facility. The frequency with which the facility is mentioned in the media, the overall patient satisfaction, and the number of mistake events would also provide effective productivity measure for the facility (Lighter & Lighter, 2013). The patient confidentiality, the number of medical errors, staff to patient ratio and patient follow up plans would also be accurate metrics to measure the productivity of Physician Care Services, Inc. How the Metric will be used in Evaluating Productivity The above-mentioned metrics would be used to evaluate the productivity of Physician Care Services, Inc. by ascertaining the effectiveness of providing care to the private and occupational patients. The metrics will provide an insight into the levels of staffing, the patient improvement plans, and effectiveness of the various medical procedures administered by the facility. The metrics would also indicate the effectiveness of the hospital staff in delivering their duties and how efficient the hospital equipment is put into use (Langabeer, 2015). In addition, the metrics would be used to indicate the number of training required to increase the competence and effectiveness of the hospital staff and also to ascertain the overall patient satisfaction. The metrics may also be sued to value the effectiveness of the facility’s revenue cycle and the capacity of the resources to improve the quality of care offered. How the Data Will Help Measure the Potential of the Organization’s Success in the New Era of Health Care Reform The data provided by the productivity metrics would be sued to measure the potential of the Physician Care Services, Inc. to achieve success in the new era of healthcare reform by ascertaining average time a patient would spend before receiving timely care. In the long run, the ability of the facility to schedule its service delivery and implement adequate staffing would provide an insight into the level of patient satisfaction (Hopp & Lovejoy, 2014). These metrics also determine the quality of care offered and thus the efficiency of the services offered by the facility can be sued to estimate its potential of achieving success. Good revenue cycle. Low claims denial rate and low average treatment charge would also indicate an effective facility. References: Hopp, W. J., & Lovejoy, W. S. (2014). Hospital Operations: Principles of high-efficiency health care. Upper Saddle River (N.J.: Pearson Education. Joint Commission Resources, Inc. (2013). Managing performance measurement data in health care. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations. Langabeer, J. R. (2015). Performance improvement in hospitals and health systems. Chicago, IL: Healthcare Information and Management Systems Society. Lighter, D. E., & Lighter, D. E. (2013). Basics of healthcare performance improvement: A lean Six Sigma approach. Burlington, MA: Jones & Bartlett Learning. Lawal et al. Systematic Reviews 2014, 3:103 http://www.systematicreviewsjournal.com/content/3/1/103 PROTOCOL Open Access Lean management in health care: definition, concepts, methodology and effects reported (systematic review protocol) Adegboyega K Lawal1*, Thomas Rotter1, Leigh Kinsman2, Nazmi Sari3, Liz Harrison4, Cathy Jeffery5, Mareike Kutz6, Mohammad F Khan7 and Rachel Flynn8 Abstract Background: Lean is a set of operating philosophies and methods that help create a maximum value for patients by reducing waste and waits. It emphasizes the consideration of the customer’s needs, employee involvement and continuous improvement. Research on the application and implementation of lean principles in health care has been limited. Methods: This is a protocol for a systematic review, following the Cochrane Effective Practice and Organisation of Care (EPOC) methodology. The review aims to document, catalogue and synthesize the existing literature on the effects of lean implementation in health care settings especially the potential effects on professional practice and health care outcomes. We have developed a Medline keyword search strategy, and this focused strategy will be translated into other databases. All search strategies will be provided in the review. The method proposed by the Cochrane EPOC group regarding randomized study designs, non-randomised controlled trials controlled before and after studies and interrupted time series will be followed. In addition, we will also include cohort, case–control studies, and relevant non-comparative publications such as case reports. We will categorize and analyse the review findings according to the study design employed, the study quality (low- versus high-quality studies) and the reported types of implementation in the primary studies. We will present the results of studies in a tabular form. Discussion: Overall, the systematic review aims to identify, assess and synthesize the evidence to underpin the implementation of lean activities in health care settings as defined in this protocol. As a result, the review will provide an evidence base for the effectiveness of lean and implementation methodologies reported in health care. Systematic review registration: PROSPERO CRD42014008853 Keywords: Lean, Systematic review, Health care, Toyota management system Background Lean is a set of operating philosophies and methods that help create maximum value for patients by reducing waste and waits [1]. It aims to fundamentally change organization thinking and value, which ultimately leads to the transformation of organization behaviour and culture over time [2]. Based on the Toyota model, it focuses on how efficiently resources are being used and ask, ‘what value is being added for the customer’ in every process [3]. Recently, the health * Correspondence: lawal.kazeem@usask.ca 1 College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon S7N 5A2, Canada Full list of author information is available at the end of the article care industry has demonstrated success in applying these principles in the United States, United Kingdom, Australia and now Canada [4]. Despite indications that lean is prevalent in health care, many authors regard its implementation to be pragmatic, patchy and fragmented [5]. The application of lean management in health care can also be holistic such as the transformation of an overall business strategy [2,6]. Although lean thinking originated from car making, research on its application and sustainability in health care is still limited [7]. Primary studies often lack appropriate concepts explicitly stated, research designs, appropriate analysis and outcome measures [7]. The majority of studies also reported on successful lean interventions, whereas little © 2014 Lawal et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lawal et al. Systematic Reviews 2014, 3:103 http://www.systematicreviewsjournal.com/content/3/1/103 has been documented about the failed attempts or barriers to its implementation in health care [7]. It is therefore imperative to catalogue and synthesize the existing literature via a systematic review on the effects of lean implementation especially the potential effects on professional practice and health care outcomes in various settings. Review questions and objectives The primary review question is as follows: What are the effects of lean management in health care on professional practice and health care outcomes? The secondary review questions are as follows: (i.)What can we learn from the existing evidence on lean to better understand the various methodologies used and the experience in evaluating the impact? (ii.)What are the differences in lean implementation, and can we explain how those differences might lead to different outcomes? Criteria for considering existing publications for this review The systematic review will include all relevant studies according to the review questions and objectives. We will apply the electronic search strategy to identify all primary studies reporting on the effectiveness of lean and the different strategies used for implementation. We will extract and collate all of the concepts used to describe lean, how it is applied and the activities involved in the implementation process. We will not include editorial reports, animal studies, lean applications in other industries, teaching and investigations using self-reported outcomes. Types of publications/studies The method proposed by the Cochrane Effective Practice and Organisation of Care (EPOC) group regarding randomized study designs (RCTs), non-randomised controlled trials (NRCTs), controlled before and after studies (CBA) and interrupted time series (ITS) will be included [8]. In addition, we will also consider cohort or panel (longitudinal) studies, case–control studies and relevant non-comparative publications such as case reports. A case report is a document that provides details about how a study was conducted and its subsequent findings. A panel study is a longitudinal study in which variables are measured on the same units over time. Types of institutions and participants All sectors of the health care system, including hospital care, primary care and rehabilitation All employees such as CEOs, health professionals, administrative staff and support staff Patients and their families Management, lean experts and key stakeholders Page 2 of 6 Types of lean interventions reported Definition Lean is a set of operating philosophies and methods that help create a maximum value for patients by reducing waste and waits [1]. The approach was originally derived from the Toyota car company production line system: a continuous process improvement system comprising of structured inventory management, waste reduction and quality improvement techniques [9]. Lean utilises a continuous learning cycle that is driven by the ‘true’ experts in the processes of health care, being the patients/families, health care providers and support staff [10]. The majority of lean investigations published in the international literature refer to the Toyota management system as applied to health care [11-18]. In particular, the Virginia Mason Medical Center’s application of lean ‘became the catalyst for lean health care’ in other health systems, particularly in the United States and the United Kingdom [19,20]. Other authors refer to Thedacare [21] or simply to a lean management system or lean principles/lean philosophy [2,22-24]. Lean application in Saskatchewan In Saskatchewan, the Toyota lean management system is used in combination with a strategic management and policy deployment system, called Hoshin Kanri [25], and daily visual management. Daily visual management is an approach where staff members take the time each day to evaluate their progress using the key elements of daily huddles and visibility walls. Types of implementation strategy reported Varying terms and Japanese terminologies are used to describe the lean implementation strategies. The most frequently reported lean implementation activities are ‘lean basics’ workshops, also described as ‘Kaizen basics’ workshops. A ‘Kaizen or lean basics’ session is a one-day workshop, introducing lean tools and techniques [6,18]. Other activities reported in the literature to implement lean in health care are 5S events to reorganize the workplace, rapid process improvement workshops (RPIW) and value stream mapping to improve current and future care processes [11-13,26]. 5S stands for ‘Sort, Sweep, Simplify, Standardize, Sustain/Self-Discipline’, and it represents a set of concepts that helps organizations ensure a clean and organized work place [27]. An RPIW is a week-long event also reported as a three-day lean event where teams of patients and their families, staff and clinicians focus on one problem, identify the root cause, create solutions and implement the solution in the workplace [27]. A value stream map in health care is a visual tool to understand the flow of patients, supplies or information through the journey of a patient, and it maps all processes required to deliver a health care service [27]. We will report on all activities used to implement Lawal et al. Systematic Reviews 2014, 3:103 http://www.systematicreviewsjournal.com/content/3/1/103 lean concepts and methodologies. More examples of activities to be included are Kanban, lean leadership training, mistake-proofing projects, and other activities used to implement the lean management system. Kanban is a visual signalling system when new parts, supplies or services are needed, in the quantity needed, and at the time they are needed. A Kanban signal is usually a card, indicating the need to reorder supplies [27]. The aim of a mistake-proofing project is to develop a device or procedure to avoid such an error in the future (e.g. specific hose coupling in anaesthesia, forcing functions in order entry) [27]. Page 3 of 6 All objectively reported process and outcome measures will be included. To be considered for this review, the studies must include one or more of the following primary or secondary outcomes. focused on lean. Since lean is not represented in controlled vocabularies of biomedical databases, an information scientist developed a Medline search strategy (see Additional file 1, Strategy B) This focused keyword strategy will be translated and run in the databases listed below. We will not make use of methodological filters and will not apply date or language limits. All search strategies will be provided in the final review. The following electronic databases will be searched for primary studies: Medline (OVID), Embase (OVID), HealthStar (OVID), Web of Science (Science, Social Sciences, and Arts & Humanites Citations Indexes and Conference Proceedings), Health Technology Assessment (HTA), Economics Evaluation (EED) databases, Cochrane Library, EconLit, PAIS (Public Affairs Information Service) International, Proquest Dissertations & Theses, Proquest Political Science and Canadian Research Index (see Additional file 1, Strategy C). Primary outcomes Other search methods Any objective measure of the following: We will also do the following: Types of outcome measures 1. Health system improvement outcomes: admission time, collection time, turnaround time, triage time, time to see a physician, dispensing time, examination room time, number of patient visit, length of stay, discharge rate, patient journey time, scheduling time, near miss event rate, turnover time, wait time, etc. 2. Patient outcomes: patient satisfaction, mortality rate, re-admission rate, etc. 3. Professional outcomes: employee satisfaction, time spent with the patient, staff overtime, login to provider time, etc. Search websites of organizations (grey literature searching) concerned with quality in health care such as AHRQ (Agency for Healthcare Research & Quality) and ASQ.org. Sites searched will be reported in the review. Contact the authors of relevant studies or reviews to clarify reported published information or to seek unpublished results/data (as needed). Contact researchers with expertise relevant to our topic (as needed). Conduct cited reference searches (in citation indexes) for studies we include in this review. Secondary outcomes Methods/Design Any objective measure of the following: Screening 1. The various types of lean definitions or concepts: lean, lean philosophy, lean principles, continuous quality improvement, etc. 2. Lean management systems: Toyota management system, Henry ford production system, Thedacare improvement system, Virginia Mason production system, etc. 3. Lean activities: 5S, Value stream mapping, Rapid process improvement workshops, Kaizens basics workshops, 3P, etc. Search strategy for the identification of studies To develop our search strategy, we ran the Medline search strategy (see Additional file 1, Strategy A) from a Cochrane review on the broad concept of continuous quality improvement [28]. However, this strategy was not All titles and abstracts will be included in a reference management database; duplicates will be deleted. Two review authors will independently screen all titles and abstracts (MFHK and MK) to assess which studies meet the inclusion criteria. We will retrieve the full text copies of all potentially relevant papers, and disagreement on the inclusion will be resolved by a third member of the research team (TR). Data management We will record and report details on the number of retrieved references, the number of full text papers obtained and the number of included and excluded articles. We will manage this data in EndNote and use an excel spreadsheet. We will categorize articles based on three types of studies as suggested by a previously published literature review on lean management in hospitals [29]. The three Lawal et al. Systematic Reviews 2014, 3:103 http://www.systematicreviewsjournal.com/content/3/1/103 article types are as follows: (1) articles that discuss the application of lean principles and are based only on the experience or general knowledge of the authors, (2) empirical articles based on actual case studies or research related to the application of lean principles and (3) literature reviews related to lean processes [29]. The reason for excluding retrieved full text studies will be stated in the final review. Data extraction Pairs of two review authors (TR and LA, RF and MK, LH and NS, LK and CJ) will independently extract data according to the double data entry method by using a standardized data extraction sheet (Excel spreadsheet); they will extract data directly from the included studies. We will refer unresolved disagreements on data abstraction to a third review author (TR and LK) and if consensus cannot be reached, the contact author of the review, LA. If necessary, we will seek additional information from the authors of the primary studies. Risk of bias assessment Two independent review authors will assess the methodological quality of all included studies, using the EPOC checklist for the assessment of methodological quality of studies [8]. EPOC criteria to be assessed include allocation of concealment, sequence generation, blinding of participants and personnel, similarities of baseline measures, confounding, similarities of baseline characteristics, management of incomplete outcome data, selective outcome reporting, contamination and other risk of bias identified by the review team. (See Additional file 2 for full list). For non-randomized designs such as case studies and cohort studies, we will use a tool for before-after studies that was developed based on the Newcastle-Ottawa scale [30] and used in a previous review [31]. Confounding factors (e.g. simultaneously ongoing initiatives such as changes in hospital policy and implementation of DRGs) will be also considered for case studies and cohort studies. The methodological quality of included studies will be assessed, and we will categorize them into three classes: A (low risk of bias), B (moderate risk of bias) and C (high risk of bias). We will refer unresolved disagreement on risk of bias to a third review author. We will consider studies with low risk of bias for all key domains or where it seems unlikely for bias to seriously alter the results. We will consider studies where risk of bias in at least one domain is unclear or judged to have some bias that could raise doubts about the conclusions as having an unclear risk of bias. We will consider studies with a high risk of bias in at least one domain or judged to have serious bias that decreases the certainty of the conclusions as having a high risk of bias [32]. We will not exclude studies from the review classified at high risk of bias. We will retain these studies and Page 4 of 6 include them in a subsequent sensitivity analysis based on the assigned risk of bias. Data analysis and synthesis For the primary review question, that is, the effects of lean management on professional practice and health care outcomes, data will be reported in natural units. For dichotomous data (i.e. odds ratio (OR) or risk ratio (RR)) we will calculate a crude event rate as a measure of overall frequency giving the total number of events occurring over the follow-up period reported unadjusted for covariates (i.e. sex, age). In the case of missing standard deviation, the appropriate transformation will be undertaken [32]. We will assess the data on resource use, costs and cost-effectiveness according to the methodology used in the individual studies [33]. Financial data will be presented in US$ for the same base year and will be adjusted for inflation by using a country-specific price index [34]. Additionally, we will provide the nominal cost data to allow readers to recalculate the results using alternative price indexes. Studies reporting in other currencies will be converted to US$ [35]. For the two secondary review questions, all relevant data will be extracted and presented in a tabular form. All outcomes will be counted and grouped in a tabular form into similar implementation activities, complications such as in-hospital complications and the direction of effect reported e.g. positive, negative and null. Relevant findings will be categorized and synthesized in the form of a narrative summary using text and evidence tables according to the definitions and implementation strategy reported in the primary study [36]. Whenever possible, we will attempt to contact the original investigators to request for missing information. For missing standard deviation, we will recalculate them from the reported statistics provided in these studies (e.g. confidence intervals, standard errors, t values, P values) [37]. Combining studies We will make an assessment of the reported lean methodologies, implementation strategies and effects, based upon the quality, size and direction of effects observed or reported. Positive, negative and null effects will be assessed, and studies will be grouped following the methods reported in the primary study. We will categorize and analyse the review findings according to the study design employed, the study quality (low- versus high-quality studies) and the method reported in the primary studies. The results will be presented in a tabular form. We expect to find both statistical and contextual heterogeneity, given the range of outcomes measured and the many different settings and types of professionals and patients included. This may make statistical pooling impossible, but if there seems be a group of studies amenable to meta-analysis, then a random-effect model will be employed with the results displayed graphically. We will assess statistical heterogeneity by visually Lawal et al. Systematic Reviews 2014, 3:103 http://www.systematicreviewsjournal.com/content/3/1/103 inspecting the confidence intervals of the effect estimates and by calculating a test of heterogeneity (I squared test I2) [38], with a cut off of 60%. Subgroup analysis We will perform a sub-group analysis of the primary and secondary outcomes reported where applicable. We will group studies according to the following categories: 1. Country(s) where the study was carried out (adjusting for possible market forces). 2. Setting(s) where the implementation of lean intervention occurred. 3. Year of publication to assess temporal differences in the outcomes reported over time Sensitivity analysis Sensitivity analysis will be carried out to explore the robustness of the results by investigating the effects of including and excluding studies with high risk of bias and studies with missing information. Ongoing studies We will describe identified ongoing studies, where available, detailing the primary author, research question(s), methods and outcome measures together with an estimate of the reporting date. Discussion Overall, the systematic review aims to identify, assess and synthesize the evidence to underpin the various types of definition, concepts, methodology and effects of lean in health care settings as defined in this protocol. As a result, the review will provide an evidence base for the effectiveness of lean and the types of implementation strategies utilized, based on the review findings and conclusions. Additional files Additional file 1: Search Strategies Lean Review. This file contain details of the search strategy ran in a particular database (Medline). Additional file 2: EPOC risk of bias criteria. This file contains the suggested risk of bias for EPOC reviews. Competing interests The authors declare that they have no competing interests. Authors’ contributions All review authors have contributed to the production of the protocol, and all authors read and approved the manuscript. LA and TR led the writing of the protocol; all other review authors provided comment and feedback. For the full review, The Cochrane EPOC trail search coordinator, Michelle Fiander, has developed and will run the search strategy together with Vicky Duncan, the Nursing Liaison Librarian at the University of Saskatchewan. MK and MFHK will screen all the titles and abstracts for eligibility. TR and LA, RF and MK, LH and NS, LK and CJ will assess all primary studies for eligibility in review phase II. All review authors will abstract data, undertake analysis and Page 5 of 6 write up the review. Michelle Fiander and VD will take the leadership regarding additional search strategies as defined in this review protocol. TR and NS will give advice on the methodological issues and the statistical analysis. LK would act as arbitrator should disagreement arise and will give advice on methodological issues. TR and LK will assess all full text studies in the second review stage about the practical relevance of the published methods. TR will lead the writing of the full review. LK and TR will critically appraise the review findings and conclusions, that is, to access the transferability of the international evidence. Acknowledgements We would like to thank Michelle Fiander, the Trial search coordinator from the Cochrane EPOC group in Ottawa for her contribution to the design of the search strategies we will use for the review. Funding The protocol development has been supported by the Saskatchewan Health Quality Council (Contract C7036). Author details 1 College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon S7N 5A2, Canada. 2School of Rural Health, Monash University, Bendigo, Australia. 3Department of Economics, University of Saskatchewan, Saskatoon, SK, Canada. 4School of Physical Therapy, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada. 5College of Nursing, University of Saskatchewan, Saskatoon, SK, Canada. 6Faculty of economy, University of Applied Sciences, Osnabrueck, Germany. 7School of Public Health, University of Saskatchewan, Saskatoon, SK, Canada. 8Faculty of Nursing, University of Alberta, Edmonton, AB, Canada. Received: 4 April 2014 Accepted: 8 September 2014 Published: 19 September 2014 References 1. JBA: Lean leader certification and maintenance – physician track (FAQs); 2014. http://www.sma.sk.ca/data/1/rec_docs/872_2013-2009-2003LLTFAQ.pdf (Accessed June 21, 2014. 2. Smith G, Poteat-Godwin A, Harrison LM, Randolph GD: Applying Lean principles and Kaizen rapid improvement events in public health practice. J Public Health Manag Pract 2012, 18(1):52–54. 3. Campbell RJ: Thinking lean in healthcare. J AHIMA 2009, 80(6):40–43. quiz 45–46. 4. Fine BA, Golden B, Hannam R, Morra D: Leading Lean: a Canadian healthcare leader’s guide. Healthc Q 2009, 12(3):32–41. 5. Burgess N, Radnor Z: Evaluating Lean in healthcare. Int J Health Care Qual Assur 2013, 26(3):220–235. 6. Ulhassan W, Sandahl C, Westerlund H, Henriksson P, Bennermo M, von Thiele SU, Thor J: Antecedents and characteristics of lean thinking implementation in a Swedish hospital: a case study. Qual Manag Health Care 2013, 22(1):48–61. 7. Mazzocato P, Holden RJ, Brommels M, Aronsson H, Backman U, Elg M, Thor J: How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Children’s hospital, Stockholm. Sweden. BMC Health Serv Res 2012, 12:28. doi:10.1186/14726963-1112-1128. 8. Effective Practice and Organisation of Care (EPOC): EPOC resources for review authors. Oslo: Norwegian Knowledge Centre for the Health Services; 2013. Available at: http://epocoslo.cochrane.org/sites/epocoslo.cochrane.org/files/ uploads/05%20What%20study%20designs%20should%20be%20included% 20in%20an%20EPOC%20review%202013%2008%2012_0.pdf. 9. Black J, Miller D: The Toyota Way to Healthcare Excellence: Increase Efficiency and Improve Quality with Lean. Chicago, IL: Health Administration Press; 2008. 10. de Souza L: Trends and approaches in Lean healthcare leadership. Leadership in Healthcare 2009, 22(2):121–139. 11. Mazzocato P, Holden RJ, Brommels M, Aronsson H, Backman U, Elg M, Thor J: How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Children’s hospital, Stockholm, Sweden. BMC Health Serv Res 2012, 12(28). http://www. biomedcentral.com/content/pdf/1472-6963-12-28.pdf. 12. Hummer J, Daccarett C: Improvement in prescription renewal handling by application of the Lean process. Nurs Econ 2009, 27(3):197–201. Lawal et al. Systematic Reviews 2014, 3:103 http://www.systematicreviewsjournal.com/content/3/1/103 13. Belter D, Halsey J, Severtson H, Fix A, Michelfelder L, Michalak K, Abella P, De Ianni A: Evaluation of outpatient oncology services using lean methodology. Oncol Nurs Forum 2012, 39(2):136–140. 14. Casey JT, Brinton TS, Gonzalez CM: Utilization of lean management principles in the ambulatory clinic setting. [Review] [35 refs]. Nat Clin Pract Urol 2009, 6(3):146–153. 15. Ford AL, Williams JA, Spencer M, McCammon C, Khoury N, Sampson TR, Panagos P, Lee JM: Reducing door-to-needle times using Toyota’s lean manufacturing principles and value stream analysis. Stroke 2012, 43(12):3395–3398. 3395. 16. Naik T, Duroseau Y, Zehtabchi S, Rinnert S, Payne R, McKenzie M, Legome E: A structured approach to transforming a large public hospital emergency department via lean methodologies. J Healthc Qual 2012, 34(2):86–97. 17. Waldhausen JH, Avansino JR, Libby A, Sawin RS: Application of lean methods improves surgical clinic experience. J Pediatr Surg 2010, 45(7):1420–1425. 1420. 18. McDermott AM, Kidd P, Gately M, Casey R, Burke H, O’Donnell P, Kirrane F, Dinneen SF, O’Brien T: Restructuring of the diabetes day centre: a pilot lean project in a tertiary referral centre in the west of Ireland. BMJ Qual Saf 2013, 22(8):681–688. 19. Wood D: Taking the pulse of lean healthcare. Healthcare quarterly (Toronto, Ont) 2012, 15(4):27–33. 20. Blackmore CC, Bishop R, Luker S, Williams BL: Applying lean methods to improve quality and safety in surgical sterile instrument processing. Joint Comm J Qual Patient Saf 2013, 39(3):99–105. 21. Barnas K: Theda Care’s business performance system: sustaining continuous daily improvement through hospital management in a lean environment. Joint Comm J Qual Patient Saf 2011, 37(9):387–399. 22. Van Vliet EJ, Bredenhoff E, Sermeus W, Kop LM, Sol JC, Van Harten WH: Exploring the relation between process design and efficiency in highvolume cataract pathways from a lean thinking perspective. Int J Qual Health Care 2011, 23(1):83–93. 23. Atkinson P, Mukaetova-Ladinska EB: Nurse-led liaison mental health service for older adults: service development using lean thinking methodology. J Psychosom Res 2012, 72(4):328–331. 24. Vegting IL, van Beneden M, Kramer MH, Thijs A, Kostense PJ, Nanayakkara PW: How to save costs by reducing unnecessary testing: lean thinking in clinical practice. Eur J Intern Med 2012, 23(1):70–75. 25. Cowley M, Domb E: Beyond Strategic Vision: Effective Corporate Action with Hoshin Planning. New York: Rutledge; 1997. 26. Esain A, Williams S, Massey L: Combining planned and emergent change in a healthcare Lean transformation. Public Money & Management 2008, 28(1):21–26. 27. JBA: John Black and Associates LLC. 25 Glossary. 2014. http://blog.hqc.sk.ca/ wp-content/uploads/2013/09/JBA-Lean-Glossary.pdf (Accessed Jan 23, 2014). 28. Brennan S, McKenzie JE, Whitty P, Buchan H, Green S: Continuous quality improvement: effects on professional practice and healthcare outcomes (Protocol). Cochrane Database Syst Rev 2009, Art. No(Issue 4):CD003319. doi:10.1002/14651858.CD003319.pub2. 29. Brackett T, Comer L, Whichello R: Do lean practices lead to more time at the bedside? J Healthc Qual 2013, 35(2):7–14. 30. Wells GSB, O’Connell J, Robertson J, Peterson V, Welch V, Losos M, Tugwell P: The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analysis; 2005. http://www.ohri.ca/programs/clinical_epidemiology/nosgen.pdf] (accessed June 26, 2014). 31. Rowe BH, Bond K, Ospina MB, Blitz S, Friesen C, Schull M, Innes G, Afilalo M, Bullard M, Campbell SG, Curry G, Holroyd B, Yoon P, Sinclair D: Emergency department overcrowding in Canada: what are the issues and what can be done? [Technology overview no 21]. Ottawa: Canadian Agency for Drugs and Technologies in Health; 2006. http://www.cadth.ca/media/pdf/422_overcrowding_to_e.pdf. 32. Higgins JP, Deeks JJ: Selecting studies and collecting data. In Cochrane Handbook for Systematic Reviews of Interventions. Edited by Higgins JP, Green S. Chichester, West Sussex: Wiley; 2008:151–185. 33. Deeks JJ HJ, Alman DG: Analyzing data and undertaking meta-analyses. In Cochrane Handboo for Systematic Reviews of Intervention. Edited by Higgins Jpt G. Chichester, West Sussex; Hoboken NJ: Wiley; 2008:243–296. 34. Shemilt I, Thomas J, Morciano M: A web-based tool for adjusting costs to a specific target currency and price year. Evidence Policy: A J Res, Debate and Practice 2010, 6(1):51–59. Page 6 of 6 35. Drummond MF, Jefferson TO: Guidelines for authors and peer reviewers of economic submissions to the BMJ. BMJ Econ

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Evaluation Working Party BMJ 1996, 313(7052):275–283. 36. NICE: Public Health Guidance -Methods Manual. National Institute for Health and Clinical Excellence. 2005. https://www.nice.org.uk/guidance/cg15/ resources/cg15-type-1-diabetes-in-children-and-young-people-evidencetable-2 (accessed Jan 31, 2014). 37. Higgins JP, Deeks JJ, Altman DG: Chapter 16: Special topics in statistics. In Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0 [Updated March 2011]. Edited by Higgins JPT, Green S: The Cochrane Collaboration; 2011. Available from http://handbook.cochrane.org/. 38. Higgins JP, Thompson SG, Deeks JJ, Altman DG: Measuring inconsistency in meta-analyses. BMJ 2003, 327(7414):557–560. doi:10.1186/2046-4053-3-103 Cite this article as: Lawal et al.: Lean management in health care: definition, concepts, methodology and effects reported (systematic review protocol). Systematic Reviews 2014 3:103. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit
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