SummaryLangley Porter Psychiatric Hospital and Clinics used Toyota Production System principles to streamline the process by which patients are transferred to outpatient clinics. Key improvements included obtaining advanced insurance authorization, enhancing patient involvement, standardizing and simplifying referral request and appointment scheduling processes, and using automated systems to track referrals and scheduling and to measure performance, thus enabling the rapid identification of sources of error and delay. The program significantly reduced scheduling time, time to the patient's first appointment, and communication errors, leading to a near doubling in the number of patient transfers completed each month.Moderate: The evidence is based on pre- and post-implementation comparisons of the amount of time needed to schedule appointments, time to the first appointment, and number of monthly transfers, along with post-implementation trend data on communication errors.
Developing OrganizationsLangley Porter Psychiatric Hospital and Clinics
Date First Implemented2006
Vulnerable Populations > Mentally ill
Problem AddressedEfficient transfer of patients from psychiatric hospitals to outpatient clinics for follow up care is a critical step in the successful treatment of adults with severe and persistent mental illness. Successful transfers require prompt scheduling and coordination of care. A number of obstacles frequently lead to delays in these efforts, causing care fragmentation and raising patients' likelihood of continued mental health problems.
- Need for prompt scheduling and care coordination: Many patients with severe mental illness require quick follow up care; however, transfers cannot occur until a variety of scheduling and care coordination steps take place, including making the transfer request, approving the transfer, identifying an appropriate clinic, contacting the clinic, scheduling an appointment, getting the clinician all appropriate records and information, and giving the patient the new clinician's contact information in case questions arise before the first appointment.1
- Obstacles to prompt transfer: Obstacles to timely transfers include complex referral systems requiring numerous individual staff reviews and approvals, communication errors between the hospital and the patient or the outpatient clinic, and poor comprehension by patients related to the importance of prompt followup. For example, at Langley Porter, transfers could originate from five different sources: outpatient assessment clinics, outpatient staff psychotherapists, inpatient units, the partial hospitalization program, and the consult-liaison service based in an adjacent medical hospital. This challenge was compounded by constantly changing clinicians because rotating residents staffed outpatient clinics.1
- Significant treatment consequences: Arranging a follow up appointment within a few days rather than a few weeks increases the likelihood of successful transfer and the establishment of a positive therapeutic relationship. By contrast, delayed transfers increase the likelihood that patients will fail to receive or complete follow up treatment. As a result, they are more likely to experience symptom exacerbations, require repeat hospitalizations, and attempt or commit suicide.2
Description of the Innovative ActivityLangley Porter Psychiatric Hospital and Clinics used Toyota Production System principles to streamline the process by which patients are transferred to outpatient clinics. Key improvements included obtaining advanced insurance authorization, enhancing patient involvement, standardizing and simplifying referral request and appointment scheduling processes, and using automated systems to track referrals and scheduling and to measure performance, thus enabling the rapid identification of sources of error and delay. Key features of the program include the following:
- Advanced insurance authorization: When any patient enters the hospital, administrative staff obtain insurance authorization for all possible services, including potential transfer to an outpatient clinic. Previously, insurance authorization for a given service was not sought until the patient was ready for transfer, causing delays.
- Increased patient involvement: Before the receiving clinician is chosen, administrative staff talk with patients about their preferred location for an outpatient clinic, as well as convenient days and times for appointments. Previously, the clinic director chose the receiving clinician and appointment time without this input, resulting in patients often failing to show up for appointments.
- Standardized, simplified request and scheduling process: The hospital uses standardized processes to ensure each patient transfer is handled in a similar, expedited manner, designating roles and responsibilities to involved parties:
- Single pathway and template regardless of referral source: One universal process guides all transfer requests—regardless of their source—with a single set of paperwork requirements. Previously, a separate pathway existed for each of the five sources of transfers. Referring clinicians use a standard template to complete and submit transfer requests. The template prompts collection of essential information that allows the clinic director to easily make a yes/no decision and provides the receiving clinician with the information needed to assume the patient's care.
- Daily logging and forwarding of requests: Hospital administrative staff retrieve written transfer requests daily, log them into a tracking sheet, and forward them to the clinic director on the same day. Previously, transfer requests were retrieved weekly.
- Deadline for director approval: The clinic director reviews the referring clinician's recommendation and must decide whether to accept or reject it within 2 business days. Previously, no deadline existed.
- Rapid input into tracking system: For approved requests, the clinic director inputs the assigned clinician into the tracking system and forwards the transfer request back to the administrative staff within 2 business days.
- Standardized communications to referring clinicians: Using a template that allows for Health Insurance Portability and Accountability Act–compliant e-mails, administrative staff report the status of transfer requests to referring clinicians, who receive one e-mail when a patient transfer request is approved and another when the appointment is scheduled. Previously, no standardized process or format existed for these communications.
- Scheduling and billing for appointments: Administrative staff schedule an appointment with the patient, then forward the written transfer request and medical records to the receiving clinician within 3 days. If a patient cannot be contacted within 3 days, the referring clinician is notified and asked to assist. If contact is not made within an additional 5 days, the transfer is canceled. Administrative staff take responsibility for billing the initial appointment for a length of 45 minutes. Previously, the receiving clinician billed the initial visit, often recording the incorrect Current Procedural Terminology (CPT) code.
- Automated systems: The new transfer process takes advantage of current software and the existing computer system for electronic tracking, scheduling, and performance measurement, thus allowing for the rapid identification and addressing of the sources of error and delay.
- Tracking: Staff members enter the date that each task has been completed for each transfer request into a spreadsheet. Previously, this information was stored in a less functional database, with a printed copy also being placed in a binder; neither the database nor the paper copy showed the current status of the transfer request. All staff can now view the spreadsheet to locate the position of any given transfer request and to identify sources of error and delay, especially at the individual staff level.
- Scheduling: Administrative staff enter all appointments into an electronic database. Previously, they entered them into a paper schedule, recording them in an electronic schedule only after the visit, which created the potential for errors and double bookings.
- Performance measurement: The hospital tracks how well it meets established goals, such as the percentage of cases in which transfer requests are retrieved the same day, the number of decisions by the clinic director that are made within 2 business days, and the number of patient scheduling and other administrative tasks that are completed within 3 days. This system enables the hospital to identify and address opportunities for improvement.
Context of the InnovationLangley Porter is part of the psychiatry department at the University of California San Francisco School of Medicine. The hospital, which has a 20-bed inpatient unit, a day hospitalization program, and outpatient adult and child clinics, is affiliated with multiple clinical training programs, including programs in psychology and adult, child, adolescent, and geriatric psychiatry. The initiative to streamline the transfer process to outpatient clinics arose from an awareness in 2005 that delays and communication errors were common and frequently involved relatively acute patients who required prompt clinical care. A near-fatal overdose by a depressed patient whose appointment at an outpatient clinic had not been effectively tracked provided additional urgency to address the issue. Hospital leaders turned to the Toyota Production System after realizing that little literature existed on reducing waiting times and optimizing patient flow between units of care for psychiatry patients and after becoming aware of the successful application of the Toyota approach to care transitions in other medical inpatient and outpatient settings.
ResultsThe program significantly reduced scheduling time, time to the patient's first appointment, and communication errors, leading to a near doubling in the number of patient transfers completed each month.
Moderate: The evidence is based on pre- and post-implementation comparisons of the amount of time needed to schedule appointments, time to the first appointment, and number of monthly transfers, along with post-implementation trend data on communication errors.
- Much less time to schedule patients: The number of days required to process transfers and establish contact with patients decreased by 87 percent, from 22 days during the April 2005 to January 2006 period (before implementation) to 5.7 days in the year after implementation (defined as phase 1 of the study, from February 2006 to February 2007), and then to 2.7 days during the March 2007 to January 2009 period (phase 2).
- Time to first appointment: The number of days from acceptance of the transfer request to the first appointment decreased by 31.2 percent in phase 1 (from 33.1 to 22.8 days) and by an additional 4.8 percent in phase 2 (from 22.8 to 21.7 days).
- Near elimination of communication errors: The number of communication errors per month—defined as the number of transfers in which the receiving clinic did not have a record of the transfer from the referring service—fell by 89 percent between phase 1 and phase 2, from 0.36 to 0.04 per month. (Analysis for this measure was restricted to the change between phases 1 and 2 because the hospital did not have reliable preintervention data.)
- Near doubling in number of transfers: The number of transfers successfully processed and scheduled each month increased by 102 percent in phase 1 (from 6.3 to 12.7). This number fell modestly (by 4 percent) in phase 2, yielding an overall increase of 95 percent between baseline and phase 2.
Planning and Development ProcessKey planning and development steps included the following:
- Team formation: In late 2005, the hospital assembled a team consisting of the director of the outpatient clinics, the hospital's practice and patient safety manager, and senior clinicians at the hospital and clinics. The team, which was charged with assessing and improving the transfer process, met weekly or biweekly for several months, with the two leaders meeting frequently between these sessions.
- Examination of existing process: With input from key stakeholders, the team developed a detailed flowchart of the existing process, identifying a number of sources of error and delay, including the following:
- Use of workarounds: Although the official transfer process was detailed in a staff manual, staff rarely consulted it. Instead, they used a complex tangle of workarounds developed over years.
- No defined responsibilities: Staff did not understand who was responsible for each step, with responsibility varying across settings, staff, and transfer requests.
- No performance measurement: The process lacked standards and mechanisms to measure performance, thus allowing little opportunity to identify and address sources of error and delay.
- Clinician dissatisfaction: Many clinicians did not know how to request transfers and/or found the process to be unreliable and unsatisfactory.
- No patient input: The process did not take into account patients' preferences for clinic location or time of day for appointments.
- Development of new process and goals: In ongoing meetings and brainstorming sessions, the team used Toyota Production System principles to design a new process, specifying the content, sequence, timing, and responsible person for each step and using a checklist to establish unambiguous connections across steps. The team also established measurable goals so performance could be monitored on an ongoing basis.
- Enhanced training: Before implementation, all staff involved in the transfer process received training on the streamlined process. Because their role was critical, administrative staff participated in training that focused on reducing data entry and process errors. New clinicians at the hospital and outpatient clinics participate in a training session on the transfer process shortly after they begin an assignment.
- Ongoing modifications: After implementation in February 2006, the team made minor adjustments in the first few months; the team continues to monitor and modify the process as needed.
Resources Used and Skills Needed
- Staffing: Development and implementation of the new transfer process required no new staff.
- Costs: No significant costs were associated with the new process.
Funding SourcesLangley Porter Psychiatric Hospital and Clinics
Tools and Other ResourcesA transfer checklist, form, and flowchart are available by e-mail request from the innovator.
Getting Started with This Innovation
- Analyze current system: Although time consuming, mapping out the existing transfer process is worthwhile. Because staff are often unaware of or ignore official instructions, it is important to determine which steps staff actually use in practice.
- Expect and work to reduce resistance: Some employees may object to changes in the transfer process because standardization reduces their autonomy. In addition, staff may be reluctant to discuss errors, such as entering data incorrectly or not meeting efficiency targets. Although some dissatisfaction is inevitable, hospital leaders can mitigate it by emphasizing the ultimate goal (improved patient care) and highlighting successes (e.g., reductions in transfer delays).
Sustaining This Innovation
- Emphasize training: All new employees should receive detailed training on their role in the transfer process. Avoid bundling this training into a general orientation. Instead, hold a discrete session focused exclusively on this topic.
Contact the InnovatorJohn Q. Young, MD, MPP
Vice Chair for Education
Department of Psychiatry
Hofstra North Shore-LIJ School of Medicine
75-59 263rd Street
Glen Oaks, NY 11004
Phone: (718) 714-8005
Innovator DisclosuresDr. Young has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesYoung JQ, Wachter RM. Applying Toyota Production System principles to a psychiatric hospital: making transfers safer and more timely. Jt Comm J Qual Patient Saf. 2009;35(9):439-48. [PubMed]
Young JQ, Wachter RM. Applying Toyota Production System principles to a psychiatric hospital: making transfers safer and more timely. Jt Comm J Qual Patient Saf. 2009;35(9):439-48. [PubMed]
Williams ME, Latta J, Conversano P. Eliminating the wait for mental health services. J Behav Health Serv Res. 2008;35:107-14. [PubMed]
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Original publication: December 23, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: November 06, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: October 25, 2013.
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.