MalikFProject#8

BUSI830 Project8 1 School of Business, Liberty University Faizan Malik DMAIC Case Study (FINAL) Assignment By submitting this assignment, I attest this submission represents my own work, and not that of another student, scholar, or internet source. I understand I am responsible for knowing and correctly utilizing referencing and bibliographical guidelines. I have not submitted this work for any other class.

BUSI830 Project8 2 Abstract The COVID-19 pandemic has transformed the landscape of healthcare delivery, emphasizing the significance of telehealth services to ensure accessible medical care. However, healthcare disparities, particularly in rural areas, persist despite technological advancements. This case study, conducted at OHSI Medical Clinic in Mentone, Texas, serves as an example of how to address the underutilization of telehealth services and improve healthcare accessibility in a remote and underserved region.

BUSI830 Project8 4 of materials and information through a process, to visualize the current telehealth process and workflow at OHSI Medical Clinic (Marin-Garcia et al., 2021). Once objectives have been clearly defined, the team will work to develop a data collection plan that outlines the plan for collecting patient data, to obtain a baseline for the processes identified via VSM. The data collection plan ensures that the data that is collected is relevant to the research questions and can help identify potential challenges for the study (Moser & Korstjens, 2018). From the data collection plan, using a mixed-methods approach, the team will utilize quantitative methodologies to collect data related to telehealth service usage from March 2020 during the peak of the pandemic up to the most recent data available and qualitative methodologies to gain insight from medical providers and their patients. This data will then provide insight into potential issues contributing to the underutilization of telehealth services, which will then be presented to OHSI Medical Clinic leadership to implement process changes, new means of training or communication, or new technology. Once the issues with underutilization have been addressed, the team will conclude their study by providing a sustainable framework for maintaining the improvements made throughout the case study to ensure OHSI Medical Clinic's telehealth services remain effective over the long term. Define Phase The OHSI Medical Clinic had initially envisioned that the implementation of telehealth services would result in increased access to healthcare during the Covid-19 pandemic, in an area that has historically been underserved in healthcare access However, OHSI Medical Clinic's leadership has indicated that the anticipated benefits have not materialized as expected with patients are not embracing telehealth options and medical providers are not witnessing the expected increase in telehealth-related appointments. With the key problem of underutilization of

BUSI830 Project8 5 telehealth services at the OHSI Medical clinic identified, the team moved directly into defining the objective of the study to understand the magnitude of the underutilization. To ensure that the defined objectives address the key problem, the team utilized value stream mapping to gain a better understanding of the clinic's telehealth service delivery process, including value-added and non-value-added steps, and identify potential contributing factors to the underutilization of telehealth services, as illustrated in Figure 1. Figure 1: Value Stream Mapping for the current telehealth process and workflow at OHSI Medical Clinic. The VSM highlighted several critical areas contributing to the underutilization of telehealth services at OHSI Medical Clinic. One key issue was the requirement for patients to register and receive their initial visit in person at the clinic, which posed a significant barrier, especially for those who couldn't travel to the facility. This limitation was compounded by the scarcity of available telehealth services for follow-up care, with the VSM highlighting that only a select group of medical providers at OHSI Medical Clinic offered telehealth services during limited timeframes, often being fully booked months in advance. This scheduling constraint further hindered patient access to telehealth services, as limited access to healthcare services, along with greater social isolation, in rural areas collectively contribute to challenges for adults in accessing and affording necessary healthcare (Cohen et al.,2018). Moreover, it was evident that OHSI

BUSI830 Project8 7 The data collection for patient demographics presented a unique challenge, as privacy and data security concerns are pivotal barriers in the realm of healthcare data collection and research. As such, the OHSI team implemented a multifaceted approach including obtaining informed consent about the risks and benefits of the study, including how their data will be collected, used, and shared, and data encryption techniques to protect against unauthorized access (Mooney & Pejaver, 2018). The patient surveys also covered a wide array of topics, ranging from satisfaction levels with telehealth experiences at OHSI Medical Clinical, difficulties or challenges faced during telehealth appointments, and, if telehealth appointments were preferred over in-person visits for routine healthcare needs in the future. Finally, the interviews with healthcare providers sought to understand the impact of telehealth offerings and suggestions for improvement. Collectively, these data collection methods provided the OHSI team with a comprehensive and multifaceted dataset, enabling a holistic understanding of telehealth utilization in their rural healthcare setting. Analyze Phase Once data collection has been completed, the OHSI team then moved to the analysis phase, in which they aimed to identify and understand the root causes of the problem that is being addressed by the DMAIC case study (Ahmed, 2019). Patient ID Age Gender Ethnicity Household Income Education Level Distance (Miles) from OHSI Medical Clinic Internet Access at Home Prior Experience with Telehealth Type of Health Insurance 1 45 Female White $50,000 - $75,000 College degree 10 Yes Yes Private 2 68 Male African American $25,000 - $50,000 High school diploma 25 Yes No Medicare 3 55 Female Hispanic Less than $25,000 Some college 5 No Yes Medicaid 4 32 Male Asian $75,000 - $100,000 Graduate degree 15 Yes Yes Private 5 70 Male White $50,000 - $75,000 College degree 30 No No Medicare 6 58 Female African American $25,000 - $50,000 Some college 12 Yes Yes Medicaid 7 40 Male Hispanic Less than $25,000 High school diploma 8 Yes No Uninsured 8 49 Female Asian $75,000 - $100,000 Graduate degree 20 Yes Yes Private 9 62 Male White $50,000 - $75,000 College degree 40 No No Medicare 10 35 Female African American $25,000 - $50,000 Some college 18 Yes Yes Medicaid Figure 3: Data collected from OHSI Medical Clinic EHR

BUSI830 Project8 8 Beginning with data collected from OSHI Medical Clinic’s HER, as illustrated in Figure 3. The patient demographic data illustrated an age range of 32 to 79 years old with varying levels of prior experience with telehealth services, indicating age may play a role in shaping patient preferences and barriers to telehealth adoption. The included patients also come from diverse ethnic backgrounds and education levels. Analyzing this data might reveal disparities in telehealth utilization among different ethnic groups or educational backgrounds, shedding light on potential access and equity issues. Income and distance from the OHSI Medical Clinic are two variables that could be interrelated, with patients having lower household incomes and those residing closer to the clinic potentially finding telehealth more attractive due to potential financial constraints or the convenience factor. Figure 4: Results from OHSI Medical Clinic patient telehealth service feedback survey Moving to the patient surveys, as demonstrated in Figure 4, the OSHI team found that the patient exhibited mostly positive satisfaction levels and an overwhelming preference for future telehealth utilization. This indicates that the majority of patients had a favorable experience with telehealth services offered by OHSI Medical Clinic and suggests that telehealth has the potential to address some of the historical barriers faced by this community. However, the survey data also pointed to a few challenges faced during telehealth appointments, specifically related to technical difficulties of internet connectivity issues. These issues highlight a known issue with healthcare

BUSI830 Project8 10 benefits and be the root cause of the limited telehealth offerings by OHSI Medical Clinical healthcare providers. Improve Phase Once in the improvement phase, the OHSI team focused on addressing the root causes identified during the Analyze Phase to optimize their telehealth services to increase adoption amongst patients. Given the size of the facility, the team opted to implement pilot studies in various departments to ensure the final recommendations provided the greatest value to the organization. As explained by Lowe (2019), during the improvement phase of DMAIC, pilot studies serve to test and refine potential solutions to identified root causes, ensuring their feasibility, effectiveness, and prevention of new problems (Lowe, 2019). The pilot studies began with enhancing technical infrastructure at OHSI Medical Clinic to combat technical issues encountered during telehealth appointments by eliminating the requirement for patients to register and receive their initial visit in person at the clinic, partnering with local internet service providers to offer discounted or subsidized broadband internet service to patients and expanding the availability of telehealth services for follow-up care (Struminger and Arora, 2019). The team then worked to address privacy and workload concerns voiced by both patients’ healthcare providers at OHSI Medical Clinic, to ultimately increase availability of providers and adoption by patients, by introducing telehealth education and training programs. These programs included telehealth case studies, simulation exercises, and hands-on training to provide healthcare providers with practical experience that covered topics of ethical considerations, data security, and patient privacy in telehealth (Chike-Harris et al., 2021). Finally, the OSHI team implemented a system for regular evaluation and feedback collection from both patients and providers, which combined are used to inform ongoing refinements and adaptations to telehealth services.

BUSI830 Project8 11 Continual feedback loops within healthcare settings have demonstrated improved patient satisfaction and outcomes (Gibbons et al., 2021). Control Phase As the combination of recommendations in the improvement phase yielded positive results for telehealth adoption by OHSI Medical Clinic patients, the OHSI was able to move into the control phase to ensure sustained success. This began with developing Standard Operating Procedures (SOPs) to outline the step-by-step processes that healthcare providers must follow when conducting telehealth appointments to ensure consistency and quality in healthcare delivery. The SOPs should address patient eligibility and consent, technology and equipment, and clinical procedures as a means of ensuring the quality and safety of telehealth services (Sugarman & Busch, 2023). The OSHI team then implemented several Key Performance Indicators (KPIs) for each department and the entire clinic to provide a quantifiable way to measure the progress of telehealth implementation and the performance of their medical providers. Following the recommendations of Chuo et al. (2020), the OHSI team implemented KPIs for number of telehealth appointments, the percentage of patients who use telehealth, average telehealth appointment duration, patient satisfaction with telehealth, provider satisfaction with telehealth, and cost savings from telehealth, to comprehensively assess the utilization, adoption, efficiency, quality, and financial impact of telehealth services (Chuo et al., 2020). The combination of SOPs and KPIs allows OHSI leadership to establish clear guidelines and expectations for telehealth service delivery while simultaneously providing a systematic and data-driven approach to utilizing telehealth services to improve patient care and outcomes.

BUSI830 Project8 13 Conclusion The COVID-19 pandemic brought to the forefront the role that telehealth services play in providing accessible healthcare, particularly in rural areas. As the world sought to reduce virus transmission, it became evident that telehealth could bridge the gap between patients and healthcare providers, offering a means of maintaining essential healthcare services even in the face of lockdowns and social distancing measures. The DMAIC case study conducted at OHSI Medical Clinic in Mentone, Texas, serves as an example of proactive efforts to tackle these disparities. By defining objectives, the OHSI team sought to understand and address the underutilization of telehealth services in their rural healthcare setting. Through a series of well- planned steps, including various Lean Six Sigma (LSS) tools such as value stream mapping, data collection, analysis, SOPs and KPIs the OHSI team ensured that the solutions were not only feasible but also effective in addressing the root causes of underutilization. While telehealth services helped bridge the gap for healthcare access disparities, there remains much left to do in terms of providing equal access to those in rural areas. Just as we’ve been commanded by God to speak up for those who cannot advocate for themselves. it is incumbent upon healthcare providers and institutions to take concrete steps to make proper healthcare accessible to all, thereby fulfilling their duty to care for the marginalized and vulnerable in society.

BUSI830 Project8 14 References Ahmed, S. (2019). Integrating DMAIC approach of Lean Six Sigma and theory of constraints toward quality improvement in healthcare.  Reviews on environmental health ,  34 (4), 427- 434. Best Neighborhood, (n.d.). Retrieved from https://bestneighborhood.org/dsl-internet-loving- county-tx/ Cohen, S. A., Cook, S. K., Sando, T. A., & Sabik, N. J. (2018). What aspects of rural life contribute to rural‐urban health disparities in older adults? Evidence from a national survey.  The Journal of Rural Health ,  34 (3), 293-303. Chike-Harris, K. E., Durham, C., Logan, A., Smith, G., & DuBose-Morris, R. (2021). Integration of telehealth education into the health care provider curriculum: a review.  Telemedicine and e-Health ,  27 (2), 137-149. Chuo, J., Macy, M. L., & Lorch, S. A. (2020). Strategies for evaluating telehealth.  Pediatrics ,  146 (5). Drake, C., Zhang, Y., Chaiyachati, K. H., & Polsky, D. (2019). The limitations of poor broadband internet access for telemedicine use in rural America: an observational study.  Annals of internal medicine ,  171 (5), 382-384. Gibbons, C., Porter, I., Gonçalves-Bradley, D. C., Stoilov, S., Ricci-Cabello, I., Tsangaris, E., ... & Valderas, J. M. (2021). Routine provision of feedback from patient‐reported outcome measurements to healthcare providers and patients in clinical practice.  Cochrane Database of Systematic Reviews , (10). Kerlin, M., O’Farrell, N., Riley, R., & Schaff, R. (2022). Rural rising: Economic development strategies for America’s heartland. McKinsey & Company .

BUSI830 Project8 16 The Holy Bible, New International Version. (2011). Blue Letter Bible. https://www.blueletterbible.org/niv/index.cfm (Original work published 1973)

BUSI830 Project8 17 Appendix 1 Patient Feedback Survey on OHSI Medical Clinic Telehealth Services 1. How satisfied are you with your telehealth experience at OHSI Medical Clinic? (Scale: Very Satisfied, Satisfied, Neutral, Dissatisfied, Very Dissatisfied) 2. Were there any technical difficulties or challenges you faced during your telehealth appointments? 3. Would you prefer telehealth appointments over in-person visits for routine healthcare needs in the future? (Yes/No) Appendix 2 OHSI Medical Clinic Healthcare Provider Interview Questionnaire 1. How has the adoption of telehealth services impacted your medical practice? 2. What do you perceive as the primary benefits of telehealth for your patients? 3. Are there any challenges or limitations you've encountered in delivering care through telehealth? 4. What improvements or changes would you recommend for optimizing telehealth service delivery at OHSI Medical Clinic?