How an Entrepreneur-in-Residence changed the culture at CMS

By Patrick Conway, MD, MSc, CMS Deputy Administrator for Innovation and Quality
Twitter: @CMSGov

When I came to The Centers for Medicare & Medicaid Services (CMS) in 2011, I pulled the results from the latest Federal Employee Viewpoint Survey – a survey of federal employee satisfaction. I discovered that CMS was in the bottom quintile for the entire Federal government. My office, the Center for Clinical Standards and Quality (CCSQ), was at the bottom of CMS.

I called an old boss after reading that to seek advice, and he said, “Well, there is a lot of room for improvement.”

Six years later, we have radically changed the culture inside the Centers for Medicare and Medicaid Services (CMS). We have saved over $100 million and improved the turn-around time for creating and implementing measures that doctors and other providers use to report Medicare quality. Here’s a window into how.

The Problem
I have to go back to the very beginning of the process. We started with what we thought was an opportunity to improve processes and procedures in the Center for Clinical Standards and Quality (CCSQ) at CMS.

At the time, we were working with the Office of the National Coordinator for Health Information Technology to make electronic clinical quality measures (eCQM) more efficient. Electronic clinical quality measures help CMS and doctors understand and track quality of care. Read about an example of a measure relating to eye exams for patients with diabetes, or more here.

The problem we were dealing with was the process to create a new electronic clinical quality measure – from being developed, proposed, approved, to implemented – took nearly 5 years and 100% of the measures had defects. This complicated process involves measure developers, contractors, specialty societies, the National Quality Forum, several federal agencies, providers, and patients. The complicated process also placed a burden on our staff and contributed to low employee morale. To make matters worse, our Quality program IT systems failed to meet the needs of the clinicians who participated in our programs, and frequently required numerous expensive changes after they had been deployed, leading to higher costs, extensive system downtime and hundreds of complaints from our users.

When I was at Cincinnati Children’s Health System, I had utilized the process improvement tool called “Lean” to improve clinical quality for patients in the operating room and in the discharge process. Lean is a methodology to reduce waste in an organization, increase value delivered to customers, and improve overall employee satisfaction.

I knew that a Lean approach to the eCQM and IT system processes could improve the development to implementation process at our office, and through engagement of those directly responsible for doing the work get better outcomes; and, as a result, improve employee satisfaction. Our office needed an expert in Lean who could start right away and be fully embedded working side-by-side with HHS and CMS employees.

Hiring Talent
The Office of the Chief Technology Officer’s (CTO) Entrepreneurs-in-Residence (EIR) Program was a perfect fit for our needs. The EIR program matches internal HHS teams wanting to tackle a critical problem at the Department with skilled innovators who are looking to make a meaningful impact and who can solve that problem.

We worked with the Office of the CTO to post and market our position description to attract innovators. After a number of interviews with a talented pool of applicants, we selected Mindy Hangsleben. Mindy has a deep background in manufacturing and Lean. Not only was she was perfect for the position, but she was on-boarded within 2 months, which is speedy for the federal government.

Culture Change
So, Mindy got to work. She trained up Lean ambassadors in every group, and they would train up their co-workers and so on. And this training helped to radically change the culture at CMS by improving overall employee satisfaction.

We reduced the process from 5 years to 2 years, for development to implementation time for eCQM measures. We also took a process that had close to 100% defects and now it has less than 5% defects. Our quality reporting IT systems are now developed using agile processes and user-centered design. We averaged over 150 post-deployment system changes, but we now have fewer than 10 and have saved over 8000 hours per year in CMS staff and contractor time. Importantly, our staff and contractors are now working to their highest level of certification and our end users, clinicians, find our systems much easier to use.

We’ve added more experts like Mindy over time, but she started the transformation. The Entrepreneurs-in-Residence program put in this catalytic factor: hiring amazing talent like Mindy.

As of 2016, CMS is now ranked 2nd federal wide – among over 50 federal health agencies – for employee satisfaction.

The other day I was walking the floor at CMS – what the Japanese call a Gemba – and I stopped to chat with an employee who works with bundled payment data. I asked her how it was going. She stopped what she was doing and literally white boarded out the process. She identified where there was waste and identified the changes she intended to make.

CMS employees were always mission driven, but they now believe they can create positive change. They believe they can improve their daily work and their opinions truly matter. If you want to improve the mission, that’s 90% of the battle.

The Future
It doesn’t stop here, we’re spreading Lean thinking to the regions, throughout every center and office at CMS. The goal is to make the system as highly reliable as possible.

I want to thank Mindy for her incredible work. Just think about it, she came into government in late 2013. In just a few years, she helped us turn around the culture at one of the largest and most important programs in government.

The Office of the CTO’s Entrepreneurs-in-Residence program connected my office with Mindy and the unique skill set that was needed to solve critical challenges at our office. Any office at HHS that is facing a critical challenge and can identify the unique skill sets needed to solve the problem should look at the Entrepreneur in Residence program. Innovators who are looking to make a meaningful impact at HHS are out there.

This article was originally published on HHS Idea Lab and is republished here with permission.