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Service Delivery Innovation Profile

Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Productivity at Community Health Clinics


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Snapshot

Summary

Denver Community Health Services, the primary care clinic component of Denver Health (Colorado's primary safety net institution), uses the Toyota "Lean" rapid cycle process improvement system to enhance efficiency in eight Federally Qualified Health Centers. As a result of these improvements, the clinic has cut patient registration time in half, increased provider productivity by 25 percent, reduced patient cycle time and the patient no-show rate, and increased revenues by approximately $3.5 million.

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of key indicators before and after implementation of the process improvements.
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Developing Organizations

Denver Health
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Use By Other Organizations

A number of organizations have applied Lean principles to the clinic setting, including Borgess Ambulatory Care in Kalamazoo, MI; New York City Health and Hospitals Corporation; and Hennepin County Medical Center in Minneapolis, MN.

Date First Implemented

2006

Problem Addressed

Many medical practices are characterized by inefficient, unproductive processes that can lead to extended wait times for patients and inefficient use of clinician and staff time. In today's environment of declining reimbursement and rising costs, these inefficiencies can undermine the financial viability of a practice.
  • Extended patient wait times: Surveys by the American Medical Association suggest that the average patient waits 19 minutes before seeing the physician.1
  • Highly variable, often long patient cycle times: Patient cycle time (the time between patient arrival and departure) varies widely across practices, from 30 minutes in highly efficient practices to 90 minutes in highly inefficient ones.1
  • Inefficient use of clinician and staff time: A major cause of long waiting and cycle times are inefficient processes that do not take full advantage of scarce clinician and staff time. Time-and-motion studies conducted in physician practices typically show many gaps in workflow, adding to inefficiency.2 Common bottlenecks include inflexible or poor scheduling, late patient arrivals, the need to look for information, and poor office setup (e.g., drug-dispensing units located far from examination rooms).2
  • Negative impact on finances: Because the vast majority of practice revenue is a function of the physician’s time, inefficient use of clinician time can have a negative financial impact. Maximizing the productivity of all providers allows a practice to serve more patients without hiring additional clinicians, which is critical to the long-term financial viability of the practice.1

What They Did

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Description of the Innovative Activity

Using key elements of the Toyota Lean Production System, Denver Community Health Services pursued process redesign in all eight of its clinics to improve appointment scheduling, provider coordination, and patient registration. (For more information on the role of Lean in this program, please see the Planning and Development section.) Key changes are described below:
  • Streamlined appointment scheduling: The clinic implemented the following changes to facilitate appointment scheduling and reduce no-shows:
    • One appointment type: Previously, the clinic offered two different appointment types—a 30-minute visit and a 15-minute visit—depending on patient circumstances (e.g., new or returning patient; well visit or visit for an acute condition). Having two different appointment lengths made it necessary for front desk staff to ask patients about their care needs and then find an appropriate time slot. Now, only one type of appointment is available, a 20-minute visit, which reduces time spent on the phone and makes it easier to find an early open slot on the schedule.
    • Designated appointment time: Rather than operating a block appointment schedule in which multiple patients are scheduled for a single block of time time (e.g., scheduling three patients at the top of the hour, resulting in some patients having to wait), the clinic now schedules each patient for a specific time, such as at 1:00 p.m., 1:20 p.m., and 1:40 p.m.
    • Stricter policy for early and late arrivals: Previously, a patient arriving an hour early would be checked in right away; now, early patients must wait until their appointment time to be checked in. Previously, patients arriving late would be worked into the schedule; now, late patients are only seen if there is room on the schedule. Otherwise, the appointment is rescheduled.
    • Policy for patient no-shows: It is now clear to patients that they should call the office if they need to cancel an appointment. They also publicize a new policy: Any patient who is a no-show twice without calling to cancel will no longer be able to make an appointment. Rather, these patients can only be served on a "walk-in" basis, with no assurance of provider availability.
    • Open-access scheduling system: The schedule leaves some slots open each day so that visits can be scheduled quickly for sick patients. Approximately 70 percent of visits are for appointments made on that same day, with only 30 percent of appointments having been made in advance.
    • No appointments made too far in advance: To reduce no-shows, appointments are not scheduled more than 2 weeks in advance. Patients who require followup care beyond the 2-week timeframe are asked to call for an appointment sometime within the 2-week window. Patient registries are used to contact patients with chronic diseases, such as asthma and diabetes, who neglect to make a followup appointment at the appropriate time.
    • Centralized scheduling under consideration: Denver Health is currently evaluating the creation of a centralized system with a single call center that would eliminate the need for each clinic to handle its own scheduling.
  • Simplified registration process: Previously, front desk staff verified address, insurance coverage, and other information with patients at every visit; now, this information is verified on a quarterly basis.
  • Provider dyads to enhance productivity: The clinic changed the work process of the physicians and medical assistants so that they work in tandem as a team rather than seeing patients sequentially:
    • Tandem, rather than sequential, care: Previously, a medical office assistant would meet with the patient first to take vital signs and ask about history, symptoms, and medications; then, a physician would enter the room and ask the same questions. Now, a physician and a medical assistant visit with the patient at the same time so that information is conveyed only once; the medical assistant enters all information into the electronic medical record while the physician offers care.
    • Standardized roles: Previously, physicians varied in how they delegated tasks to the medical assistant. Now, the clinic has standardized the roles of the doctor, medical assistant, and nurses in the practice.
    • Designated teams: Initially, the provider dyads were variable according to staffing—that is, any physician could be paired with any medical assistant. However, even with standardized roles, the clinic found that small differences in physician work processes still existed. To address potential inefficiencies, the clinic now defines the provider dyad so that the same pair of providers works together each day, allowing the two to develop a familiarity with each other and a standard process to enhance efficiency.
  • Redesigning "desktop management" tasks: Denver Health has redesigned several “desktop management” tasks (patient care–related activities completed without the patient present), such as filling out patient forms, refilling medications, and obtaining and communicating laboratory test results. The goal is—to the extent possible—to take work that does not require a face-to-face visit away from providers, giving it instead to support staff. Key changes include the following:
    • 72-hour turnaround policy for forms: Previously, patients who dropped off forms (e.g., sports physical forms, back-to-work forms, durable medical equipment authorizations, prior authorizations) received little instruction as to when they would be completed. As a result, patients often called repeatedly to check on the status of a form. In response, Denver Health established a 72-hour turnaround policy, with all patients being clearly informed that they can either pick up the form or have it mailed to them after 72 hours. As a result, staff no longer spend time handling inquiries as to the status of a form. Denver Health has also relieved physicians of many of the duties related to filling out such forms, having nurses and support staff do them instead.
    • Centralized medication refills, Pap smear followup: Denver Health has switched from having each clinic handle medication refills to using a central distribution site for all refills. Nurses who previously spent significant amounts of time handling refills at a single clinic have been reassigned to the central distribution site where they work directly with a pharmacist, handling refill requests across all clinics. This approach frees up significant time for clinic-based nurses. The same concept is being implemented for followup to Pap smear testing.

Context of the Innovation

Denver Community Health Services, a division of Denver Health (Colorado’s primary safety net provider), provides primary care services through 8 family health centers, 12 school-based clinics, and 2 urgent care centers employing 61 physicians, 80 registered nurses, and 47 allied health providers. The Federally Qualified Health Center has 320,000 patient contacts annually, serving a population that is largely Hispanic (80 percent) and either covered by Medicaid (representing 55 percent of patients) or uninsured (40 percent). Roughly 90 percent of patients have incomes below 200 percent of the Federal poverty line. The clinic became involved in organizational process improvement as a result of Denver Health's focus on efficiency improvement as an organizational goal. In pursuing this goal, Denver Health's CEO and executive staff assessed several different process improvement methods, including Lean, Six Sigma, and the Institute for Healthcare Improvement's Breakthrough Series Collaborative Approach. The executive team selected Lean because they believed it offered the most efficient and rapid improvement system.

Did It Work?

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Results

The process improvements resulted in significant improvements in provider productivity, patient registration time, patient cycle time, and no-show rates, leading to a significant increase in clinic revenues. Specific improvements include:
  • Enhanced productivity: The number of patient visits per provider 4-hour session increased by roughly 25 percent, from 8 to 9.9. The annual number of "users" (i.e., unique patients cared for by the clinics) increased by roughly 4 percent in 2008, with no increase in staffing and no negative impact on patient satisfaction or clinical outcomes.
  • Reduced registration time: The average registration time per patient was cut in half, from 4 to 2 minutes; this is a meaningful time savings considering that the clinics register thousands of patients each week.
  • Reduced patient cycle time: The provider dyad system reduced patient cycle time by 34 percent, from 88 to 58.4 minutes.
  • Fewer no shows: The patient no-show rate declined from 21 percent to 15 percent.
  • Higher revenues: Clinic revenues have increased by roughly $3.5 million as a result of the Lean-inspired improvements in patient flow (as of December 2009).

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of key indicators before and after implementation of the process improvements.

How They Did It

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Planning and Development Process

The Lean Production System is a process improvement system developed by Toyota Motor Company that incorporates different tools and techniques that can help businesses reduce waste, lower costs, and enhance productivity while increasing quality. Initially embraced by manufacturing companies, Lean methods are being implemented in a growing number of health care organizations. The clinic undertook the following planning and development steps in adopting Lean process improvement methodologies:
  • Executive buy-in: Executive leadership embraced the Lean system as a way to promote change and encouraged mid-level managers to support the system as well.
  • Training: Contracted with a consultant (Simpler, Ottumwa, IA) to train staff and facilitate improvement activities. More than 100 clinic managers have undergone the 1-week training sessions to date.
  • In-house staff: Seven in-house facilitators and one facilitator manager were hired to assist with preparation for the process improvement activities and collecting metrics; these facilitators have been trained along with clinic managers on the Lean technique.
  • Rapid improvement events: Process improvements are developed and implemented during 4-day "rapid improvement events." This Lean-adopted event is a method by which improvements can be designed and tested, with the goal of eliminating process steps that do not have any value. Participants work as cross-functional teams of managers and staff routinely involved in the process in question, with a trained on-staff clinic facilitator assisting them in their work. In some cases patients and/or community members participate as well. The 4-day event includes the following:
    • Day 1: Determining which process to improve, defining which elements of that process are value-added and which are wasteful, and creating a roadmap of the subcomponents of the process.
    • Day 2: Creating a roadmap of an ideal process, discussing barriers, reviewing potential metrics, and brainstorming suggested process changes.
    • Day 3: Defining metrics and testing suggested changes.
    • Day 4: Implementing one of the changes.
    • Ongoing: Measuring improvements on a weekly basis using a "production board" that lists metrics and ongoing performance on each metric.
  • Strategic planning: Executive leadership meets annually to map a plan for the projects to be undertaken that year; leadership also meets several times a year to review overall activities and assess progress.

Resources Used and Skills Needed

  • Staffing: Most people participate in the program as a part of their regular duties. New "staff" include the seven facilitators and one facilitator manager.
  • Costs: The costs of the program include consulting/training costs, facilitator and facilitator manager compensation, and staff time in developing and implementing the rapid improvement events. The cost of this activity cannot be easily determined because facilitators work across a number of "value streams" in addition to primary care.
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Funding Sources

Agency for Healthcare Research and Quality; Denver Health
The program was funded internally by Denver Health, with a grant from the Agency for Healthcare Research and Quality covering the initial evaluation.end fs

Tools and Other Resources

In March 2009, the Institute for Healthcare Improvement held its 10th Annual International Summit on Redesigning the Clinical Office Practice. A number of presentations from that conference discuss the application of Lean to the office-based setting. Links to all available presentations from that conference can be found at http://www.ihi.org/offerings/conferences/Summit2009/Pages/default.aspx.

Adoption Considerations

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Getting Started with This Innovation

  • Limit focus of improvement: Do not attempt to improve too many processes at once. A narrower focus will be more likely to be successful. Pursue changes that are meaningful for the system, fairly straightforward, easily measurable, and able to be accomplished within the scope of a defined improvement project.
  • Obtain training: Because Lean is a systematized methodology of pursuing process improvement, formal training and education is required.
  • Ensure support at the top levels of organization: Process improvement will not be successful if only middle management is supportive.
  • Let front-line staff drive process: Letting front-line staff (rather than senior management) identify needed changes and drive the improvement process ensures that changes are grounded in the reality of the work and that workers embrace and feel empowered by the new process, thus building staff loyalty.

Sustaining This Innovation

  • Hold frequent events: During the first year (2006), Denver Health held only one rapid improvement event at each of the eight clinics. Leaders found that this was not adequate to truly promote change. In 2007, Denver Health limited the number of participating clinics to three, holding three events at each.
  • Track metrics: Without measurement, there is no way to know whether the team is making progress.
  • Be persistent: Although Lean can yield quick improvements in the clinic setting, it should generally be considered a long-term process. Organizations that stick with Lean will continue to see improvements, even in processes in which substantial waste has already been eliminated.

Use By Other Organizations

A number of organizations have applied Lean principles to the clinic setting, including Borgess Ambulatory Care in Kalamazoo, MI; New York City Health and Hospitals Corporation; and Hennepin County Medical Center in Minneapolis, MN.

More Information

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Contact the Innovator

Paul Melinkovich, MD
Director, Community Health Services
Denver Health
777 Bannock St. MC 0278
Denver, CO 80204-4507
Phone: (303) 602-4954
E-mail: paul.melinkovich@dhha.org

Innovator Disclosures

Dr. Melinkovich has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

Footnotes

1 Woodcock, E. Mastering patient flow: more ideas to increase efficiency and earnings. Englewood, CO: Medical Group Management Association; 2003.
2 Martin E. Running behind? Try re-engineering. ACP/ASIM Observer. July/August 2000. Available at: http://www.acponline.org/clinical_information/journals_publications/acp_internist/jul-aug00
/reengineering.htm
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: April 23, 2009.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.