By Beth Blevins
Using Lean, a concept originally developed to eliminate waste in Japanese manufacturing, the New York State Office of Rural Health (NYSORH) recently embarked on a project to find more efficiency in the way its operates. The effort was part of the New York State’s broader Lean Initiative.
“This seemed very bureaucratic when we first began and we were not entirely enthusiastic about it,” said Karen Madden, NYSORH Director, “but we knew that it was something that we needed to do. So we decided to have open minds about it. We took a lot of time to be prepared and reviewed all of our data prior to our first Lean meeting, which allowed us to hit the process running.”
Although the New York State government (NYS) began its Lean efforts in 2013, it was the first time that NYSORH had used Lean. “It hadn’t gotten to us yet,” Madden explained. “Some of the projects they did were high profile and larger scale, and things that had very long processing times. But the eventual goal is to have every person who works in the NYS Department of Health trained on Lean or have them do at least one Lean project.”
For its first effort, NYSORH applied Lean principles to how it develops amended contracts, with the goal of eliminating excessive back and forth with contractors on contract requirements, Madden said. “It ended up improving our process, which we initially didn’t think needed improving, and was a great team building exercise,” she said.
Although completed last summer, NYSORH continues to apply Lean principles to its contract work, Madden said. “We continue to monitor each step of the process and compare actual times with targets that we established as part of our Lean process,” she said. “We identify outliers and discuss the issues that are causing delayed processing. Additionally, we periodically review our guidance to our grantees because that was something that we improved and that helped improve the timeliness of our approvals.”
The NYS Lean project began with four pilot agencies and has now grown to include over 41 agencies and authorities across the state. Madden said that some examples of processes that have been “leaned” in NYS include processing times for contract review and approval, voucher review and approval, application reviews, and site surveys.
Lean also has been used in other state government agencies, including Iowa and Colorado, and federal agencies including the U.S. Environmental Protection Agency.
Although NYSORH has received no additional funding for its Lean work, Madden said, “Lean has become part of how we operate now.”
When asked if other SORHs should use Lean principles, Madden answered, “We all have processes that we need to follow that we don’t necessarily have much control over, but there are likely ways that the process can run more smoothly if you take the time to break it down and find out where things slow down and why.”
“It doesn’t take a formal process or facilitator to do that,” Madden added. “It just takes a little time and an open mind to maybe do things differently and get out of the ‘that’s the way we’ve always done it’ mindset.”
“We are all part of larger organizations and need to do things that we don’t necessarily want to do, but very often something that seemed negative can be very positive if you are fully present,” Madden concluded.
Corporate sponsors are not only an important resource for funding for the mission of NOSORH, they are experts in rural health and often partners to the State Offices of Rural Health. This important work will be featured in a series of articles over the next few months.
For over a decade, State Offices of Rural Health have committed significant time and resources toward developing statewide Critical Access Hospital performance improvement networks. Likewise for over a decade Stroudwater Associates has supported the work of NOSORH and State Offices of Rural Health. . The result of this effort and focus has been the formation of mature, effective networks that enable CAHs to learn from one another, share performance data and collaborate on improvement projects.
“Stroudwater is proud to support the mission and goals of the National Organization of State Offices of Rural Health. In a rapidly changing environment with increasingly vulnerable rural providers and communities, we feel it is essential that organizations such as NOSORH continue to play a central, vital role in coordinating resources for state partners, hospitals, clinics and providers,” says Gregory Wolf, Principal with Stroudwater Associates.
Stroudwater Associates is a private healthcare consulting firm with corporate offices in Portland, Maine, Atlanta, Georgia, and Nashville, Tennessee, and experience working in all 50 states. Their Rural Team is passionate about the health of rural people and places. They tout their belief in relationship development, collaborative strategies, and commitment to personal learning and growth; with roughly half of their national practice committed to rural provider organizations.
Stroudwater supports nearly a dozen State Offices of Rural Health on their statewide performance improvement activities. Two SORH who recently shared their work on convening rural hospital networks that have a common partnership with Stroudwater Associates are the New York and Massachusetts Flex Programs.
In New York State, the Flex grant provides funding for a comprehensive performance improvement network that integrates Quality and Financial benchmarking, technical assistance and rapid-cycle projects for all of the state’s 19 CAHs. Every quarter the CEOs, CFOs and Quality Improvement Directors from every CAH across the state meet for a one-day Improvement Summit where market trends and updates are shared, state and national benchmarks are analyzed, and breakout sessions for collaborative improvement projects are convened. The New York SORH and Stroudwater partner on agenda development, meeting facilitation and methods for spreading the findings generated from the rapid-cycle project management process, the cornerstone of the Learning and Action Network. Karen Madden, the SORH Director and past NOSORH President, has witnessed the evolution of the CAH network: “Over the past several years we’ve seen increased involvement from all of our CAHs where we have almost 100% participation at every meeting from multiple managers from every hospital. But the most important advance for us has been the work that happens between our meetings. With the full implementation of the Learning and Action Network, the CAHs now work on collaborative improvement plans throughout the year and use the network meetings to learn from one another and share their successes. The level of engagement, accountability and improvement from our CAHs has been truly transformational.”
In Massachusetts, the Office of Rural Health faces a unique set of opportunities and challenges. The Commonwealth has a relatively small number of rural hospitals, most of those facilities are owned by large urban health systems, and two of the CAHs are located on islands. How does the Massachusetts SORH navigate this complex environment? “Our team has to be creative, flexible and highly collaborative,” states Cathleen McElligott, the SORH Director. “When we do our CAH network planning and consensus building with CEOs it’s essential that our Flex program activities factor in geography, hospital ownership and our state’s dynamic health reform environment. Stroudwater plays a key role in that process because they offer not just rural expertise, but also a higher level of credibility and knowledge to help our CAHs define and communicate the strategic relevance of our network activities to the health system leadership.” Like their counterparts in New York, the Massachusetts CAHs meet for full-day Improvement Summits throughout the year to review comparative analytics, address strategic and operational priorities and collaborate on rapid-cycle improvement activities.
Back to April Branch
The National Advisory Committee on Rural Health and Human Services (NACRHHS) is comprised of nationally recognized rural health experts who advise the Secretary of the Department of Health and Human Services on ways to address health care issues across rural America. Committee members offer first-hand experience dealing with rural issues in fields ranging from medicine, nursing and public health, to law, finance and research. As the only NOSORH member on the committee, it’s New York SORH Director Karen Madden’s job to provide the state office’s unique perspective on rural health care. “My role on the committee is to represent NOSORH and the state offices,” Madden said.
Every year the 21 member committee chooses specific topics to focus on during the year. The Affordable Care Act and rural homelessness are two of the key topics for 2014. By the end of the year the committee will write a report for the secretary with their recommendations on the subjects. The committee also writes white papers on specific policy issues.
“Being on the committee is very different from anything I’ve done before.We focus on policies at a very high level but also have the opportunity to talk with people in rural communities about the impact of those policies,” said Madden. “I have done work on the state and national level before, but this is such a great opportunity to work with and learn from people from so many different backgrounds.”
To read NACRHHS policy briefs, go to http://www.hrsa.gov/advisorycommittees/rural/publications/index.html
Back to September Branch
The New York Office of Rural Health (NY SORH) is playing an essential role in a new commission that is looking at how to develop an effective, integrated health care delivery system that will serve all communities in New York’s North Country. (The North Country is composed of nine counties in the northern part of the state, encompassing 13,100 square miles.)
The North Country Health System Redesign Commission (NCHSRC) was created by Governor Andrew Cuomo in December 2013 to examine preventative, medical, behavioral and long-term care services in the region. “When my boss (the Deputy Commissioner for the Office of Primary Care and Health Systems Management) informed me that the Governor created the Commission, we put together a team of folks from various Centers and Divisions in the Department and we were off and running,” said Karen Madden, director of the NY SORH.
For its involvement so far, Madden said the NY SORH has set the agendas with the Commission Chair and Co-Chairs, identified speakers to address local initiatives, handled meeting logistics, prepared background information, and worked with other Department of Health staff to clarify data and organize presentations. Additionally, the SORH contributed to the final report, which was issued in April.
That report, Toward an Integrated Rural Health System: Building Capacity and Promoting Value in the North Country, found that the region’s health is “sub-par” and that its health care delivery system is highly fragmented. It recommended the development of an integrated approach to care and a system that emphasizes prevention, increases primary care, builds more community-based options, strengthens coordination and communication, supports critical safety net providers, and monitors and rewards quality.
Madden said that despite the many negatives stated in the report, some positives were found. “I think the positives are the various local initiatives that were underway, and building upon those activities to create a stronger, financially viable system. But,” she added, “the most challenging issue remains the rurality of the region and its low population density.”
As the work of the Commission goes forward, Madden said that she and her Office “are building on our previous activities of supporting networks and encouraging all providers to develop strong affiliations. New York recently received an $8 billion Medicaid waiver to restructure the entire system and we are working with rural providers to ensure that their communities are actively engaged in those efforts. The programs included in the waiver are a major component of the recommendations in the North Country report.”
In addition, the NY SORH is working on the NCHSRC Action Plan to help implement the report’s recommendations, which Madden thinks will take approximately two years, and will be involved with a report that will detail the progress.
Back to June Branch